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									Nurse Practitioner                                                                                   Section II

    SECTION II – NURSE PRACTITIONER
    CONTENTS

    200.000          NURSE PRACTITIONER GENERAL INFORMATION
        201.000      Arkansas Medicaid Requirements for Participation in the Nurse Practitioner Program
        201.001      Electronic Signatures
        201.100      Group Providers
        201.200      Providers in Arkansas and Bordering States
        201.210      Providers in Non-Bordering States
        201.300      Certification for Registered Nurse Practitioner/Advanced Practice Nurse
        202.000      Medical Records Nurse Practitioners are Required to Keep
        203.000      The Nurse Practitioner’s Role in the Medicaid Program
        203.100      The Nurse Practitioner’s Role in the Pharmacy Program
        203.200      The Nurse Practitioner’s Role in the Child Health Services (EPSDT) Program
        203.300      The Nurse Practitioner’s Role in the ARKids First-B Program
        203.400      Nurse Practitioner’s Role in Early Intervention Reporting for Children from Birth to
                     Three Years of Age
        203.500      The Nurse Practitioner’s Role in Family Planning Services
        203.600      The Nurse Practitioner’s Role in Hospital Services
        203.700      The Nurse Practitioner’s Role in Preventing Program Abuse
        204.000      Role of Quality Improvement Organization (QIO)
    210.000          PROGRAM COVERAGE
        211.000      Introduction
        212.000      Advanced Nurse Practitioner
        213.000      Scope
        214.000      Coverage
        214.100      Exclusions
        214.200      General Nurse Practitioner Services
        214.210      General Nurse Practitioner Services Benefit Limits
        214.300      Family Planning
        214.310      General Family Planning Services Information
        214.320      Family Planning Services Demonstration Waiver
        214.321      Family Planning Services for Women in Aid Category 61, PW-PL
        214.330      Nurse Practitioner Family Planning Services
        214.331      Basic Family Planning Visit
        214.332      Periodic Family Planning Visit
        214.333      Contraception
        214.400      Injections
        214.500      Laboratory and X-ray Services Referral Requirements
        214.510      Laboratory and X-ray Services Benefit Limits
        214.600      Obstetrical Services
        214.610      Covered Nurse Practitioner Obstetrical Services
        214.620      Risk Management Services for High Risk Pregnancy
        214.630      Fetal Non-Stress Test
        214.700      Hospital Services
        214.710      Inpatient Services
        214.711      Medicaid Utilization Management Program (MUMP)
        214.712      Evaluation and Management
        214.713      Professional Components of Diagnostic and Therapeutic Procedures
        214.714      Inpatient Hospital Benefit Limits
        214.720      Outpatient Hospital Services
        214.721      Emergency Services
        214.722      Non-Emergency Services
        214.800      Occupational, Physical and Speech Therapy
        214.810      Occupational, Physical and Speech Therapy Guidelines for Retrospective Review

                                                                                                   Section II-1
Nurse Practitioner                                                                                 Section II

        214.811      Occupational and Physical Therapy Guidelines
        214.812      Speech-Language Therapy Retrospective Review Guidelines
        214.900      Procedures for Obtaining Extension of Benefits
        214.910      Extension of Benefits for Laboratory and X-Ray Services
        214.920      Completion of Request Form DMS-671, ―Request For Extension of Benefits for
                     Clinical, Outpatient, Laboratory and X-Ray Services.‖
        214.930      Documentation Requirements
        214.940      Reconsideration of Extensions of Benefits Denial
        214.950      Beneficiary Due Process
        214.951      Appealing an Adverse Decision
        214.952      Requesting Initiation or Continuation of Services Pending the Outcome of an Appeal
    220.000          PRIOR AUTHORIZATION
        221.000      Procedure for Obtaining Prior Authorization
        221.100      Post-Procedural Authorization
        221.110      Post-Procedural Authorization Process for Recipients Under Age 21
        221.200      Prescription Prior Authorization
        221.300      Procedures that Require Prior Authorization
        222.000      Appeal Process for Medicaid Recipients
    230.000          REIMBURSEMENT
        231.000      Method of Reimbursement
        232.000      Rate Appeal Process
    250.000          BILLING PROCEDURES
        252.000      Introduction to Billing
        252.000      CMS-1500 Billing Procedures
        252.100      Nurse Practitioner Procedure Codes
        252.110      Payable CPT Procedure Codes
        252.120      Payable HCPCS Procedure Codes
        252.130      Payable Local Codes
        252.200      National Place of Service (POS) Codes
        252.210      National Place of Service (POS) Codes
        252.300      Billing Instructions – Paper Claims Only
        252.310      Completion of CMS-1500 Claim Form
        252.400      Special Billing Procedures
        252.410      Clinic or Group Billing
        252.420      Evaluations and Management
        252.421      Initial Visit
        252.422      Detention Time (Standby Service)
        252.423      Inpatient Hospital Visits
        252.424      Hospital Discharge Day Management
        252.425      Nursing Home Visits
        252.426      Specimen Collections
        252.428      Services Not Considered a Separate Service from an Office Visit
        252.429      Health Examinations for ARKids First B Recipients and Medicaid Recipients Under
                     Age 21
        252.430      Family Planning Services Program Procedure Codes
        252.431      Family Planning Services Program Laboratory Procedure Codes
        252.440      Injections
        252.441      Chemotherapy
        252.442      Injections With Restrictions
        252.443      Other Covered Injections
        252.444      Billing Procedures for Rabies Immune Globulin and Rabies Vaccine
        252.445      Epoetin Alpha Injections for Non-ESRD Use
        252.446      Administration of Epoetin Alpha Injections for Chronic or Acute Renal Failure
        252.447      Immunizations For Recipients Under Age 21

                                                                                                 Section II-2
Nurse Practitioner                                                                                       Section II

        252.448      Vaccines for Children Program
        252.449      Influenza Virus Vaccine
        252.450      Obstetrical Care and Risk Management Services for Pregnancy
        252.451      Fetal Non-Stress Test
        252.452      Newborn Care
        252.460      Outpatient Hospital Services
        252.461      Emergency Services
        252.462      Non-Emergency Services
        252.463      Outpatient Hospital Surgical Procedures
        252.464      Multiple Surgery
        252.465      Observation Status
        252.466      Billing Examples
        252.470      Prior Authorization Control Number
        252.480      Medicare
        252.481      Services Prior to Medicare Entitlement
        252.482      Services Not Medicare Approved

    200.000          NURSE PRACTITIONER GENERAL INFORMATION

    201.000          Arkansas Medicaid Requirements for Participation in the Nurse                  11-1-09
                     Practitioner Program

        The Arkansas Medicaid Program enrolls registered nurse practitioners or advanced practice
        nurses for participation in the Nurse Practitioner Program. Nurse Practitioner Program providers
        must meet the Provider Participation and enrollment requirements contained within Section
        140.000 of this manual as well as the following criteria to be eligible to participate in the
        Arkansas Medicaid Program:
        A.    The provider must be licensed by the state authority in the state in which services are
              furnished.

        B.    The following documents must be submitted with the provider application and Medicaid
              contract:
              1.     A copy of all certifications and licenses verifying compliance with enrollment criteria
                     for the specialty to be practiced. (See Section 201.300 of this manual.)
              2.     Providers have the option of enrolling in the Title XVIII (Medicare) Program. If
                     enrolled in Title XVIII, the provider must inform the Medicaid Provider Enrollment
                     Unit of his or her Medicare number. Out-of-state providers must submit a copy of
                     their Title XVIII (Medicare) certification.
              3.     Providers who have prescriptive authority must furnish documentation of their
                     prescriptive authority certification. Any changes in prescriptive authority must be
                     immediately reported to Arkansas Medicaid.

    201.001          Electronic Signatures                                                          10-8-10

        Medicaid will accept electronic signatures provided the electronic signatures comply with
        Arkansas Code 25-31-103.

    201.100          Group Providers                                                                 5-1-09

        Group providers of Nurse Practitioner services must meet the following criteria in order to be
        eligible for participation in the Arkansas Medicaid Program.

        If a nurse practitioner is a member of a group, each individual nurse practitioner and the group
        must both enroll according to the following criteria:

                                                                                                       Section II-3
Nurse Practitioner                                                                                        Section II

        A.    Each individual nurse practitioner within the group must enroll following the criteria
              established in Section 201.000.

        B.    All group providers are ―pay to‖ providers only. The service must be performed and billed
              by a Medicaid-enrolled, registered nurse practitioner or advanced practice nurse within the
              group.

    201.200          Providers in Arkansas and Bordering States                                        5-1-09

        Providers in Arkansas and the six bordering states (Louisiana, Mississippi, Missouri, Oklahoma,
        Tennessee and Texas) that satisfy Arkansas Medicaid participation requirements may be
        enrolled as routine services providers.

        Routine services providers may furnish and claim reimbursement for services covered by
        Arkansas Medicaid, subject to benefit limitations and coverage restrictions set forth in this
        manual.

    201.210          Providers in Non-Bordering States                                                 3-1-11

        A.    Providers in states not bordering Arkansas may enroll in the Arkansas Medicaid program
              as limited services providers only after they have provided services to an Arkansas
              Medicaid eligible beneficiary and have a claim or claims to file with Arkansas Medicaid.

              To enroll, a non-bordering state provider must download an Arkansas Medicaid application
              and contract from the Arkansas Medicaid Web site and submit the application, contract
              and claim to Arkansas Medicaid Provider Enrollment. A provider number will be assigned
              upon approval of the provider application and the Medicaid contract. View or print the
              provider enrollment and contract package (AppMaterial). View or print Provider
              Enrollment Unit Contact information.

        B.    Limited services providers remain enrolled for one year.
              1.     If a limited services provider provides services to another Arkansas Medicaid
                     beneficiary during the year of enrollment and bills Medicaid, the enrollment may
                     continue for one year past the most recent claim’s last date of service, if the
                     enrollment file is kept current.
              2.     During the enrollment period, the provider may file any subsequent claims directly to
                     the Medicaid fiscal agent.
              3.     Limited services providers are strongly encouraged to file subsequent claims through
                     the Arkansas Medicaid Web site because the front-end processing of web-based
                     claims ensures prompt adjudication and facilitates reimbursement.

    201.300          Certification for Registered Nurse Practitioner/Advanced Practice                 5-1-09
                     Nurse

        The registered nurse practitioner must be certified as a registered nurse practitioner by the state
        in which services are furnished.

        Advanced practice nurses must hold certification from a nationally recognized certifying body
        approved by the state in which services are furnished. Certification must be in the category and
        the specialty for which the advanced practice nurse is educationally prepared.

    202.000          Medical Records Nurse Practitioners are Required to Keep                      11-1-09

        A.    Nurse practitioners are required to keep the following records and, upon request, to furnish
              the records to authorized representatives of the Arkansas Division of Medical Services and


                                                                                                        Section II-4
Nurse Practitioner                                                                                         Section II

              the state Medicaid Fraud Unit and to representatives of the Centers for Medicare and
              Medicaid Services (CMS):
              1.     History and physical examinations.
              2.     Chief complaint on each visit.
              3.     Tests and results.
              4.     Diagnoses.
              5.     Service or treatment, including prescriptions, or a referral to a physician for
                     prescriptions, and record of physician referral or consultation.
              6.     Signature or initials of the nurse practitioner after each visit.
              7.     Copies of records pertinent to any and all services delivered by the nurse practitioner
                     and billed to Medicaid.
              8.     Records must include the service date of each service billed to Medicaid.
        B.    Patient records must support the levels of service billed to Medicaid, in accordance with
              the American Medical Association’s Common Procedural Terminology (CPT) standards.

        C.    All required records must be kept for a period of five (5) years from the ending date of
              service; or, until all audit questions, appeal hearings, investigations or court cases are
              resolved, whichever period is longer.

        D.    Furnishing patient medical records on request to authorized individuals and agencies
              listed above in part A is a contractual obligation of providers enrolled in the Medicaid
              Program. Failure to furnish medical records upon request may result in the imposition of
              sanctions. (See Section 142.300 for additional information regarding record keeping
              requirements).

        E.    All documentation must be made available to representatives of the Division of Medical
              Services during normal business hours at the time of an audit conducted by the Medicaid
              Field Audit Unit. All documentation must be available at the provider’s place of business.
              If an audit determines that recoupment is necessary, there will be only thirty (30) days after
              the date of the recoupment letter in which additional documentation will be accepted.
              Additional documentation will not be accepted at a later date.

    203.000          The Nurse Practitioner’s Role in the Medicaid Program

    203.100          The Nurse Practitioner’s Role in the Pharmacy Program                             8-15-09

        Medicaid covers prescription drugs in accordance with policies and regulations set forth in this
        section and pursuant to orders (prescriptions) from authorized prescribers. The Arkansas
        Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program
        (MPPPP) which was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990.
        This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical
        companies that have signed rebate agreements. Except for drugs in the categories excluded
        from coverage, Arkansas Medicaid covers all drug products manufactured by companies with
        listed labeler codes.

        An advanced nurse practitioner with prescriptive authority (verified by the Certificate of
        Prescriptive Authority Number issued by the licensing authority of the state in which
        services are furnished) may only prescribe legend drugs and controlled substances
        identified in the state licensing rules and regulations. Medicaid reimbursement will be
        limited to prescriptions for drugs in these schedules.



                                                                                                         Section II-5
Nurse Practitioner                                                                                        Section II

        A.    Prescribers must refer to the Arkansas Medicaid Web site at
              https://www.medicaid.state.ar.us/InternetSolution/Provider/pharm/scripinfo.aspx to
              obtain the latest information regarding prescription drug coverage.

              As additions or deletions by labelers are submitted to the state by Centers for Medicare
              and Medicaid Services (CMS), the Web site is updated.

        B.    The following procedures are to be followed when prescribing drugs for Medicaid
              beneficiaries:
              1.     In addition to the prescriber’s normal procedure for prescribing drugs, the prescriber
                     must include his or her provider identification number on all prescriptions for
                     Medicaid beneficiaries whether or not the drug prescribed is a controlled substance.
                     The prescriber’s provider identification number is essential for tracking and utilization
                     review purposes.
                     The requirement to include the prescriber’s provider identification number is a
                     condition of participation in the Arkansas Medicaid Program. Administrative
                     sanctions will be imposed for noncompliance. If prescription pads are not preprinted
                     with the prescriber’s name, it is essential that the physician’s signature be legible.
              2.     When the prescriber determines that a particular brand is medically necessary, the
                     prescriber must write ―This Brand Medically Necessary‖ in his or her own handwriting
                     on the face of the prescription. A rubber stamp is not acceptable. The statements
                     ―Do not substitute‖ or ―Dispense as written‖ are not sufficient. For prescriptions
                     ordered by telephone, a written prescription that includes the required statement
                     must also be provided to the pharmacist.
        C.    Coverage Limitations
              1.     Medicaid-eligible beneficiaries aged 21 and older are limited to three prescriptions
                     per month, each filled for a maximum of one month’s supply. Extensions of an
                     individual’s drug benefit up to six prescriptions per month may be considered for
                     reasons of medical necessity. The prescribing provider must request an extension.
              2.     A prescription may be filled for a maximum of one month’s supply. A thirty-one day
                     supply is allowed.
              3.     Up to five refills within six months of the date the prescription is issued are covered if
                     specified by the prescriber. Renewals or continuations of drug therapy beyond six
                     months require another prescription.
              4.     Prescriptions for any family planning item will not be counted toward the
                     beneficiary’s monthly three-prescription limit.
              5.     Medicaid beneficiaries under age 21 are not subject to the prescription benefit limit.
              6.     Long-term care (LTC) certified Medicaid beneficiaries are not subject to the
                     prescription benefit limit.
                     LTC patients must receive prescribed drugs within a specific period of time after the
                     prescriber’s order. For prescribed drugs that require PA and are administered in oral
                     dosage forms for which a 5-day supply may be calculated and dispensed, one 5-day
                     supply of the drug may be provided to the LTC beneficiary upon receipt of the
                     prescription and reimbursed by Arkansas Medicaid without receipt of PA.
                     Within 5 days of the prescription of a PA drug for which no PA has been obtained,
                     the pharmacist and the physician shall consult to determine if there is a
                     therapeutically equivalent drug that does not require PA. The results of the
                     consultation shall be documented in writing.
                     If a non-PA, therapeutically equivalent drug exists, the physician will immediately
                     write a substitute prescription for the non-PA drug

                                                                                                        Section II-6
Nurse Practitioner                                                                                    Section II

              7.     Cough and cold preparations are not covered except for those listed on the Web site
                     at https://www.medicaid.state.ar.us/InternetSolution/Provider/pharm/scripinfo.aspx
                     in the covered cough and cold products list. Coverage is restricted to Medicaid-
                     eligible beneficiaries under age 21 and for certified long-term care beneficiaries.
                     Any OTC cough and cold products listed at the Web site are not covered for certified
                     long term care beneficiaries.
              8.     OTC products are not covered except for those listed on the Web site at
                     https://www.medicaid.state.ar.us/InternetSolution/Provider/pharm/scripinfo.aspx in
                     the covered over-the-counter products list. OTC products are not covered for
                     certified long term care beneficiaries.
              9.     When prescribing pharmaceuticals to Medicaid beneficiaries who are excluded from
                     the beneficiary cost-sharing coinsurance/copayment policy, the prescribing provider
                     must write ―Excluded from copay‖ on the face of the prescription. (Refer to Section I
                     of this manual for more information.)

    203.200          The Nurse Practitioner’s Role in the Child Health Services (EPSDT)           5-1-06
                     Program

        The Child Health Services (EPSDT) program is a federally mandated child health component of
        Medicaid. It is designed to bring comprehensive health care to individuals eligible for medical
        assistance from birth until their 21st birthday. The purpose of this program is to detect and
        treat health problems in the early stages and to provide preventive health care, including
        necessary immunizations. Child Health Services (EPSDT) combines case management and
        support services with periodic screening, as well as diagnostic and treatment services delivered.

        A primary care physician (PCP) may refer a child to a nurse practitioner to administer an EPSDT
        screen. A provider of nurse practitioner services may recommend to the PCP that an EPSDT
        screen could be necessary for any child that is thought to need one. If a nurse practitioner
        discovers a problem as a result of an EPSDT screen, or receives a referral as a result of an
        EPSDT screen, nurse practitioner services may be provided after consulting with the child’s
        PCP.
        A.    Treatment means physician, hearing, visual, dental, nurse practitioner services and any
              other type of medical care and services recognized under State law to prevent or correct
              disease or abnormalities detected by screening or by diagnostic procedures.

        B.    Nurse practitioners and other health professionals who do Child Health Services (EPSDT)
              screening may diagnose and treat health problems discovered during the screening or
              may refer the child to other appropriate sources for treatment.

        C..   If a condition is diagnosed through a Child Health Services (EPSDT) screen that requires
              a treatment service not normally covered under the Arkansas Medicaid Program, the
              service will also be considered for reimbursement if it is medically necessary and
              permitted under federal Medicaid regulations.

        D.    Effective for dates of service on and after May 1, 2006, nurse practitioners may bill a sick
              visit and a periodic Child Health Services (EPSDT) screening for a patient on the same
              date of service. This visit must be billed electronically, or on paper using form CMS-1500.
              View a form CMS-1500 sample form.

        Refer to Section I of this manual for additional information. Providers of Child Health Services
        (EPSDT) should refer to the Child Health Services (EPSDT) provider manual.

    203.300          The Nurse Practitioner’s Role in the ARKids First-B Program                10-13-03

        The ARKids First-B Program, established by Arkansas Act 407 of 1997, extends health care
        coverage to Arkansas’ uninsured children. The health care delivery network for ARKids First-B

                                                                                                    Section II-7
Nurse Practitioner                                                                                      Section II

        Program is ConnectCare. ConnectCare is the Primary Care Physician (PCP) Managed Care
        Program utilized by the Arkansas Medicaid Program.

        Preventive health screens are covered in the ARKids First–B Program for ARKids First-B eligible
        children from birth through age 18. Preventive health screens are similar to EPSDT screens.
        With the exception of routine newborn care, preventive health screens must be performed by the
        primary care physician (PCP) or referred by the PCP to an appropriate provider for screening. If
        a nurse practitioner receives a referral from the child’s PCP for a screen and a problem is
        discovered, treatment may be provided with consultation from the PCP.

        Nurse practitioners enrolled as a Medicaid provider may request an ARKids First-B provider
        manual for participation in the ARKids First-B Program. Providers should refer to their ARKids
        First-B provider manual for more information.

    203.400          Nurse Practitioner’s Role in Early Intervention Reporting for                10-13-03
                     Children from Birth to Three Years of Age

        Part C of the Individuals with Disabilities Education Act (IDEA ’97) mandates the provision of
        early intervention services to infants and toddlers, ages birth to thirty-six months of age. Health
        care providers offering any early intervention services to an eligible child must refer the child to
        the Division of Developmental Disabilities Services for possible enrollment in First Connections,
        the Part C Early Intervention Program in Arkansas. Federal regulations at 34 CFR
        303.321.d.2.ii require health care professionals to refer potentially eligible children within two
        days of identifying them as candidates for early intervention.
        A.    A child must be referred if he or she is age birth to three years and meets one or more of
              the following criteria:
              1.     Developmental delay – a delay of 25% or greater in one of the following areas of
                     development:
                     a.   Physical (gross/fine motor).
                     b.   Cognitive.
                     c.   Communication.
                     d.   Social/emotional.
                     e.   Adaptive and self-help skills.
              2.     Diagnosed physical or mental condition – examples of such conditions include but
                     are not limited to:
                     a.   Down’s Syndrome and chromosomal abnormalities associated with mental
                          condition.
                     b.   Congenital syndromes associated with delays such as Fetal Alcohol
                          Syndrome, intra-uterine drug exposure, prenatal rubella, severe microcephaly
                          and macrocephaly.
                     c.   Maternal Acquired Immune Deficiency Syndrome (AIDS).
                     d.   Sensory impairments such as visual or hearing disorders.
        B.    The Division of Developmental Disabilities Services (DDS) within the Department of
              Human Services is the lead agency for early intervention as required in Part C of IDEA in
              Arkansas. Referrals to First Connections may be made either through the DDS Service
              Coordinator for the child’s county of residence or directly to a DDS licensed community
              program.

    203.500          The Nurse Practitioner’s Role in Family Planning Services                    10-13-03

        Arkansas Medicaid encourages reproductive health and family planning by covering a
        comprehensive range of family planning services provided by nurse practitioners and other
                                                                                                      Section II-8
Nurse Practitioner                                                                                         Section II

        providers. Medicaid recipients’ family planning services benefits are in addition to their other
        medical benefits. Family planning services do not require PCP referral.
        A.    Refer to Sections 214.300 through 214.333 of this manual for family planning coverage
              information.

        B.    Refer to Sections 252.430 and 252.431 of this manual for family planning services special
              billing instructions and procedure codes.

        C.    Arkansas Medicaid also covers family planning services for women in two limited aid
              categories:
              1.     Pregnant Women-Poverty Level (PW-PL, Aid Category 61) and
              2.     Family Planning Waiver (FP-W, Aid Category 69).
              Refer to Sections 214.320 and 214.321 for more information regarding coverage of family
              planning services for these eligibility categories.

    203.600          The Nurse Practitioner’s Role in Hospital Services                              10-13-03

        A.    Medicaid covers medically necessary hospital services, within the constraints of the
              Medicaid Utilization Management Program (MUMP) and applicable benefit limitations.
              (Refer to Section 214.711.)

        B.    The care and treatment of a patient must be under the direction of a licensed physician, a
              licensed nurse practitioner, a certified nurse-midwife or dentist with hospital staff affiliation.

        C.    Arkansas Foundation for Medical Care, Inc., (AFMC) is the Medicaid agency’s Quality
              Improvement Organization (QIO). AFMC performs the following services:
              1.     AFMC reviews for the Medicaid Utilization Management Program (MUMP) all
                     inpatient hospital transfers and all inpatient stays longer than four days.
              2.     AFMC also performs post-payment reviews of hospital stays for medical necessity
                     determinations.
        D.    Hospital claims are also subject to review by the Medicaid Peer Review Committee or the
              Medical Director for the Medicaid Program.
              1.     If Medicaid denies a hospital’s claim for lack of medical necessity, payments to
                     nurse practitioners for evaluation and management services incidental to the
                     hospitalization are subject to recoupment by the Medicaid agency.
              2.     Nurse practitioners and hospitals may not bill a Medicaid recipient for a service
                     Medicaid has declared not medically necessary.
              3.     Nurse practitioners and hospitals may not bill inpatient services previously denied for
                     lack of medical necessity as outpatient services.

    203.700          The Nurse Practitioner’s Role in Preventing Program Abuse                       10-13-03

        A.    The Arkansas Medicaid Program has the responsibility for assuring quality medical care
              for its recipients along with protecting the integrity of the funds supporting the program.
              The Division of Medical Services is committed to this goal by providing staff and resources
              to the prevention, detection and correction of abuse. However, this task can only be
              accomplished through the cooperation and support of the provider community. The nurse
              practitioner is many times in a position to detect certain program abuses.

        B.    A nurse practitioner who has reason to suspect either recipient or provider abuse or
              unacceptable quality of care should contact the Utilization Review Section of Arkansas
              Division of Medical Services. An investigation will then be made. View or print the
                                                                                                         Section II-9
Nurse Practitioner                                                                                     Section II

              Arkansas Division of Medical Services Utilization Review Section contact
              information.

        C.    Examples of the types of abuse you may detect include:
              1.     Recipient over-utilization of services
              2.     Recipient misuse or inappropriate utilization of services
              3.     Recipient misuse of I.D. card
              4.     Poor quality of service
              5.     Provider over-utilization or abuse

    204.000          Role of Quality Improvement Organization (QIO)                               10-13-03

        The Quality Improvement Organization (QIO) reviews all federally and state funded hospital
        inpatient services. The purpose of such review is the promotion of effective, efficient and
        economical delivery of health care services of proper quality and assurance that such services
        conform to appropriate professional standards. QIO reviews are mandated to assure that
        federal payment for such services will take place only when they are determined to be medically
        necessary, consistent with professionally recognized health care standards and provided in the
        most appropriate setting and location.

        A pattern of aberrant practice may result in a nurse practitioner having his or her waiver of
        liability revoked. Once a nurse practitioner has lost his or her waiver of liability, 100% of his or
        her admissions are reviewed by QIO. After the appeal process, QIO forwards any denials to the
        state agency for recoupment of funds.


    210.000          PROGRAM COVERAGE

    211.000          Introduction                                                                 10-13-03

        The Medical Assistance (Medicaid) Program is designed to assist eligible Medicaid recipients in
        obtaining medical care within the guidelines specified in Section I of this manual. All Medicaid
        benefits are based upon medical necessity. See the Glossary of this manual for ―medical
        necessity‖ definition.

    212.000          Advanced Nurse Practitioner                                                  10-13-03

        A nurse practitioner, as applicable to this program, is a licensed professional nurse who meets
        the participation requirements and enrollment criteria for advanced practice nursing as defined
        by the state licensing authority.

        The nurse practitioner provides direct care to individuals, families and other groups in a variety
        of settings including homes, hospitals, nursing homes, offices, industries, schools and other
        institutions and health care settings. The service provided by the nurse practitioner is directed
        toward the delivery of primary, secondary and tertiary care that focuses on the achievement and
        maintenance of optimal functions in the population.

        The nurse practitioner engages in independent decision-making about the health care needs of
        clients and collaborates with health professionals and others in making decisions about other
        health care needs. The nurse practitioner plans and initiates health care programs as a member
        of the health care team. The nurse practitioner is directly accountable and responsible for the
        quality of care provided.

    213.000          Scope                                                                        10-13-03



                                                                                                    Section II-10
Nurse Practitioner                                                                                       Section II

        The scope of the Nurse Practitioner Program includes Medicaid covered services provided by
        pediatric, family, obstetric-gynecologic (women’s health care) and gerontological nurse
        practitioners in accordance with state and federal regulations.

        Services provided through the Nurse Practitioner Program include:
        A.    Assessment and diagnostic services.

        B.    Development and implementation of treatment plans.

        C.    Evaluation of client outcomes.

        D.    Referrals to appropriate providers when the health status of the Medicaid-eligible
              individual requires additional diagnostic and treatment services based on the health status
              of the individual.

    214.000          Coverage                                                                      10-13-03

        Many nurse practitioner services covered by the Arkansas Medicaid Program have coverage
        restrictions or are benefit limited. Coverage restrictions are the circumstances under which
        certain services will be covered. Benefit limits are the limits on the quantity of covered services
        Medicaid-eligible individuals may receive. Benefit limits for some services may be extended if
        medically necessary. Sections 214.000 through 214.800 provide information about covered
        nurse practitioner services with restrictions and/or benefit limits.

    214.100          Exclusions                                                                    10-13-03

        Exclusions are those services not covered in Arkansas Medicaid Nurse Practitioner Program
        and any covered services furnished by a nurse practitioner that are not within the scope of
        practice of the advanced nurse practitioner as defined by the state licensing authority and by the
        national certifying body. Services are not covered when provided by an employed or contracted
        nurse practitioner who is not enrolled as a participant in the Nurse Practitioner Program.

        Medicaid does not cover services that are not medically necessary or are not generally accepted
        by the medical profession. Medicaid does not cover services that are not properly documented
        by diagnoses that certify medical necessity.

    214.200          General Nurse Practitioner Services                                           10-13-03

        A.    Services provided by a nurse practitioner include initial visits and established patient visits
              for:
              1.     Diagnosis and evaluation.
              2.     Treatment services.
              3.     Health management services for prevention and early intervention.
              4.     Appropriate referrals to other health care providers for diagnostic and treatment
                     services.
        B.    Some services (pelvic exams, prostate massages, removal of sutures, etc.) are not
              considered a separate service from an office visit.

    214.210          General Nurse Practitioner Services Benefit Limits                             3-15-10

        For beneficiaries aged 21 and older, services provided in a nurse practitioner’s office, a patient’s
        home or nursing home are limited to 12 visits per state fiscal year (July 1 through June 30).

        A. Extensions of the established benefit limit are not available.

                                                                                                      Section II-11
Nurse Practitioner                                                                                       Section II

              The following services are counted toward the 12 visits per state fiscal year limit
              established for the Nurse Practitioner program:

              1.     Advanced nurse practitioner services.

              2.     Physician services in the office, patient’s home or nursing facility.

              3.     Rural health clinic (RHC) encounters.

              4.     Medical services provided by a dentist.

              5.     Medical services furnished by an optometrist.

              6.     Certified nurse-midwife services.

        B.    The established benefit limit does not apply to individuals under age 21.

        Global obstetric fees are not counted against the 12-visit limit. Itemized obstetric office visits are
        counted in the limit.

        Extensions of the benefit limit will be considered for services beyond the established benefit limit
        when documentation verifies medical necessity. Refer to Section 214.900 of this manual for
        procedures for obtaining extension of benefits.

    214.300          Family Planning

    214.310          General Family Planning Services Information                                    7-1-07

        Arkansas Medicaid encourages reproductive health and family planning by covering a
        comprehensive range of family planning services provided by nurse practitioners, physicians,
        clinics and hospitals.
        A.    Medicaid beneficiaries’ family planning services benefits are generally not benefit limited
              when providers file claims specifically as family planning services. Refer to Sections
              252.430 and 252.431 of this manual for complete family planning services billing
              information.
              1.     Abortion is not a family planning service in the Arkansas Medicaid Program.
              2.     Family planning services do not require primary care physician (PCP) referral.
              3.     Family planning prescriptions are not benefit limited, except for implantable
                     contraceptive capsule (e.g., Norplant).
        B.    Nurse practitioners desiring to participate in the Medicaid Family Planning Services
              Program may do so by providing the services described in Sections 214.330 through
              214.333 of this manual to Medicaid-eligible beneficiaries of childbearing age.

        C.    Nurse practitioners choosing not to provide family planning services may refer their
              patients to other providers, such as Arkansas Department of Health local health units,
              physicians, rural health clinics, federally qualified health centers and family planning
              clinics. Beneficiaries and others may review provider listings at local DHS county offices
              for names, addresses and telephone numbers of area providers qualified to provide family
              planning services.

        D.    Medicaid claims filed for family planning services must indicate a family planning
              diagnosis, including a family planning procedure code. If Medicaid pays for family planning
              services not identified as such, those services count against the Medicaid client’s annual
              benefit limits for professional and outpatient visits and lab and X-ray services.

                                                                                                      Section II-12
Nurse Practitioner                                                                                      Section II


    214.320          Family Planning Services Demonstration Waiver                                 10-13-03

        A.    Arkansas Medicaid administers a Family Planning Services Demonstration Waiver. This
              waiver extends Medicaid coverage of family planning services to women throughout
              Arkansas who:
              1.     Have a family income at or below 133% of the Federal poverty guidelines and
              2.     Are of childbearing age. The target population is women age 14 to age 44, but all
                     women at risk of unintended pregnancy may apply for Family Planning Services
                     Demonstration Waiver (FP-W) eligibility.
        B.    Women certified eligible under this waiver will generally remain Medicaid-eligible for the
              duration of the waiver. Loss of FP-W eligibility occurs only when an FP-W woman:
              1.     Moves out of the state,
              2.     Becomes Medicaid-eligible in another aid category,
              3.     Becomes pregnant or
              4.     Requests that her case be closed.
        C.    Women in the FP-W category are eligible for Medicaid coverage of family planning
              services only. An electronic eligibility transaction response identifies the clients as Aid
              Category 69 (FP-W).

    214.321          Family Planning Services for Women in Aid Category 61, PW-PL                  10-13-03

        Women in aid category 61, Pregnant Woman – Poverty Level (PW-PL), are eligible for
        Medicaid-covered family planning services. The Medicaid Program expects, however, that
        many of those women who desire family planning services will apply for and obtain eligibility
        under the Family Planning Services Demonstration Waiver. Recipients in aid category 61 are
        eligible for family planning services through the last day of the month in which the 60th day
        postpartum falls.

    214.330          Nurse Practitioner Family Planning Services

    214.331          Basic Family Planning Visit                                                   10-13-03

        Medicaid covers one basic family planning visit for each client per state fiscal year (July 1
        through June 30). The basic visit comprises the following:
        A.    Medical history and medical examination, including head, neck, breast, chest, pelvis,
              abdomen, extremities, weight and blood pressure.

        B.    Counseling and education regarding:
              1.     Breast self-exam.
              2.     The full range of contraceptive methods available.
        C.    Counseling and education for HIV/STD prevention.

        D.    Prescription for any contraceptives selected by the recipient. Nurse practitioners without
              prescriptive authority must arrange for a physician to prescribe the selected
              contraceptives.

        E.    Laboratory services, including, as necessary:
              1.     Pregnancy test.

                                                                                                     Section II-13
Nurse Practitioner                                                                                         Section II

              2.     Hemoglobin and hematocrit.
              3.     Sickle Cell screening.
              4.     Urinalysis testing for albumin and glucose.
              5.     Papanicolaou (PAP) smears for cervical cancer.
              6.     Testing for sexually transmitted diseases.

    214.332          Periodic Family Planning Visit                                                  10-13-03

        The purpose of the periodic visits is to evaluate the patient’s contraceptive program, to renew or
        change the contraceptive prescription and to provide the patient with additional opportunities for
        counseling regarding reproductive health and family planning.

        Medicaid covers three periodic family planning visits for each recipient per Arkansas state fiscal
        year. The periodic visit includes:
        A.    Follow-up medical history.

        B.    Weight and blood pressure.

        C.    Counseling regarding contraceptives and possible complications.

    214.333          Contraception                                                                   10-13-03

        A.    Prescription and Non-Prescription Contraceptives
              1.     Medicaid covers birth control pills and other prescription contraceptives through a
                     family planning prescription benefit.
              2.     Medicaid covers non-prescription contraceptive items as a family planning
                     prescription benefit when an authorized prescriber writes a prescription for the items.
              3.     Coverage of family planning prescriptions is in addition to the recipient’s monthly
                     prescription drug benefit.
        B.    Implantable Contraceptive Capsules (Norplant)
              1.     Medicaid covers implantable contraceptive capsule kits, such as the Norplant
                     System, through the family planning prescription drug benefit.
              2.     Alternatively, Medicaid reimburses nurse practitioners for supplying the kit at the
                     time of insertion.
              3.     Medicaid covers the insertion, removal, and removal with reinsertion when
                     performed by a nurse practitioner.
              4.     The benefit limit for the kit and insertion of the kit is two each per five-year period per
                     recipient.
              5.     The benefit limit for removal of the kit is only once per five-year period, with or
                     without reinsertion.
        C.    Intrauterine Device (IUD)
              1.     Medicaid covers the IUD through the client’s family planning prescription drug
                     benefit.
              2.     Alternatively, Medicaid reimburses nurse practitioners who supply the IUD at the
                     time of insertion.
              3.     Medicaid covers IUD insertion and removal performed by nurse practitioners.
        D.    Medroxyprogesterone Acetate (Depo-Provera)

                                                                                                        Section II-14
Nurse Practitioner                                                                                         Section II

              Medicaid covers injections of medroxyprogesterone acetate for contraceptive use,
              150 mg.

        E.    Sterilization

              Medicaid covers sterilization procedures when provided by a physician. The nurse
              practitioner may refer a patient to a Medicaid enrolled physician for sterilization
              procedures. The following conditions and benefit limits apply to delivery of these services.
              1.     Adult (age 21 or older) female Medicaid recipients who are mentally competent are
                     eligible for sterilization procedures and medically necessary annual (per state fiscal
                     year) follow-ups as long as they remain Medicaid-eligible.
              2.     Adult (age 21 or older) male Medicaid recipients who are mentally competent are
                     eligible for sterilization procedures and medically necessary annual (per state fiscal
                     year) follow-ups as long as they remain Medicaid-eligible.
              3.     Adult (age 21 or older) women in the Family Planning Waiver category, Aid Category
                     69 (FP-W), who are mentally competent, are eligible for sterilization procedures. For
                     women in this aid category, Medicaid also covers an annual post-sterilization follow-
                     up visit, when medically necessary, for each year they remain eligible under the
                     Family Planning Waiver.
              4.     Family planning services, including sterilization, are also covered for women in the
                     Aid category 61, PW-PL (Pregnant Woman – Poverty Level). Eligibility in this
                     category is through the last day of the month in which the 60th day postpartum falls.

    214.400          Injections                                                                    10-13-03

        The Arkansas Medicaid Program covers injections for treatment purposes and for immunization
        against many diseases. Some covered injections have coverage restrictions and/or benefit
        limits. Procedure codes for injections that are payable to the nurse practitioner may be found in
        the latest edition of the American Medical Association’s Current Procedural Terminology (CPT)
        and HCPCS procedure codes listed in Section 252.442 of this manual.
        A.    The following list includes the types of injections covered:
              1.     Chemotherapy for malignant disease.
              2.     Injections when there is a diagnosis of malignant neoplasm or HIV disease
                     (including AIDS) is indicated.
              3.     Desensitization (allergy) injections for recipients in the Child Health Services
                     (EPSDT) Program.
              4.     Childhood immunizations and those covered for adults.
              5.     Other covered injections for specific diagnoses and/or conditions.
        B.    The Arkansas Medicaid Program applies benefit limits to the following covered injections:
              1.     Maternal measles/mumps/rubella (MMR) is covered for women aged 21 through 44
                     who may be at risk of exposure to these illnesses. It is limited to two (2) injections
                     per lifetime.
              2.     Rho D immune globulin, human, one dose package, is limited to one (1) per
                     pregnancy.
              3.     Leuprolide acetate implant is limited to one every 12 months.

    214.500          Laboratory and X-ray Services Referral Requirements                           10-13-03




                                                                                                        Section II-15
Nurse Practitioner                                                                                      Section II

        A nurse practitioner referring a Medicaid recipient for laboratory, radiology or machine testing
        services must specify an ICD-9-CM diagnosis code for each test ordered, and include in the
        order, pertinent supplemental diagnosis supporting the need for the test(s).
        A.    Diagnostic facilities, hospital labs and outpatient departments performing reference
              diagnostics rely on the referring nurse practitioner to establish medical necessity.

        B.    The diagnoses provide documentation of medical necessity to the reference diagnostic
              facilities performing the tests.

        C.    Nurse practitioners must follow the Centers for Medicare and Medicaid Services (CMS)
              requirements for medical claim diagnosis coding when submitting diagnosis coding with
              their orders for diagnostic tests.

        D.    The Medicaid agency will enforce the CMS requirements for diagnosis coding, as those
              requirements are set forth in the ICD-9-CM volume concurrent with the referral dates and
              the claim dates of service.

        E.    ICD-9-CM diagnosis codes V72.5 and V72.6 may not be utilized.

    214.510          Laboratory and X-ray Services Benefit Limits                                 10-13-03

        The Medicaid Program’s laboratory and X-ray services benefit limits apply to outpatient
        laboratory services, radiology services and machine tests.
        A.    Medicaid has established a maximum paid amount (benefit limitation) of $500 per state
              fiscal year (July 1 through June 30) for recipients aged 21 and older, for outpatient
              laboratory and machine tests and outpatient radiology. Exceptions are listed below:
              1.     There is no lab or X-ray benefit limit for recipients under age 21.
              2.     There is no benefit limit on laboratory services related to family planning. Refer to
                     Section 252.431 of this manual for the family planning-related clinical laboratory
                     procedures.
              3.     There is no benefit limit on laboratory, X-ray, and machine-test services performed
                     as emergency services, and approved by Arkansas Foundation for Medical Care,
                     Inc., (AFMC) for payment as emergency services.
              4.     The claims processing system automatically overrides benefit limitations for services
                     supported by the following diagnosis:
                     a.    Malignant Neoplasm (ICD-9-CM codes 140.0 through 208.91)
                     b.    HIV disease and AIDS (ICD-9-CM code 042)
                     c.    Renal failure (ICD-9-CM codes 584 through 586)
        B.    Extension of benefit requests are considered for clients who require supportive treatment,
              such as dialysis, radiation therapy or chemotherapy, for maintaining life.

        C.    Benefits may be extended for other conditions documented medically necessary.

    214.600          Obstetrical Services                                                         10-13-03

        The Arkansas Medicaid Program covers obstetrical services for Medicaid-eligible recipients in
        full coverage aid categories with a medically verified pregnancy.

        Aid category 61, PW-PL are eligible for limited coverage that includes antepartum services,
        services for any condition that may complicate the pregnancy, delivery, postpartum services and
        family planning services. Aid category 61, PW-PL pregnant woman’s eligibility ends on the last
        day of the month in which the 60th postpartum day falls.

                                                                                                     Section II-16
Nurse Practitioner                                                                                     Section II

        Aid category 62, PW-PE coverage is limited to outpatient services only.

    214.610          Covered Nurse Practitioner Obstetrical Services                            10-13-03

        Covered nurse practitioner obstetrical services may be provided when medically necessary and
        are limited to antepartum and postpartum care. Appropriate referrals will be made to a physician
        and/or a certified nurse-midwife for complete obstetrical services to include delivery.

    214.620          Risk Management Services for High Risk Pregnancy                              7-1-05

        A nurse practitioner may provide risk management services if he or she employs the
        professional staff indicated in service descriptions below. If a nurse practitioner does not
        choose to provide high-risk pregnancy services but believes the patient would benefit from such
        services, he or she may refer the patient to a clinic that offers the services.

        Covered risk management services described in parts A through E below are considered as one
        service with a benefit limit of 32 cumulative units. The early discharge home visit described in
        part F is considered as a separate service.
        A.    Risk Assessment

              Risk assessment is defined as a medical, nutritional and psychosocial assessment by a
              nurse practitioner or a registered nurse on the nurse practitioner’s staff, to designate
              patients as high or low risk.
              1.     Medical assessment using the Hollister Maternal and/or Newborn Record System or
                     equivalent form includes:
                     a.   Medical history
                     b.   Menstrual history
                     c.   Pregnancy history
              2.     Nutritional assessment includes:
                     a.   24 hour diet recall
                     b.   Screening for anemia
                     c.   Weight history
              3.     Psychosocial assessment includes criteria for an identification of psychosocial
                     problems that may adversely affect the patient’s health status.
              Maximum: 2 units per pregnancy

        B.    Case Management Services

              Case management services are provided by a nurse practitioner, a licensed social worker
              or registered nurse to assist pregnant women eligible under Medicaid in gaining access to
              needed medical, social, educational and other services (e.g., locating a source of services,
              making an appointment for services, arranging transportation, arranging hospital
              admission, locating a physician to deliver a newborn, following up to verify that the patient
              kept her appointment, rescheduling the appointment).

              Maximum: 1 unit per month. A minimum of two contacts per month must be provided. A
              case management contact may be with the patient, other professionals, family and/or
              other caregivers.

        C.    Perinatal Education

              Educational classes provided by a health professional (physician, public health nurse,
              nutritionist or health educator) include:

                                                                                                   Section II-17
Nurse Practitioner                                                                                       Section II

              1.     Pregnancy
              2.     Labor and delivery
              3.     Reproductive health
              4.     Postpartum care
              5.     Nutrition in pregnancy
              6.     Maximum: 6 classes (units) per pregnancy
        D.    Nutrition Consultation — Individual

              Nutrition consultation services provided for high-risk pregnant women by a registered
              dietitian or a nutritionist eligible for registration by the Commission on Dietetic Registration
              must include at least one of the following:
              1.     An evaluation to determine health risks due to nutritional factors with development of
                     a nutritional care plan
              2.     Nutritional care plan follow-up and reassessment as indicated
              Maximum: 9 units per pregnancy

        E.    Social Work Consultation

              Services provided for high-risk pregnant women by a licensed social worker must include
              at least one of the following:
              1.     An evaluation to determine health risks due to psychosocial factors with
                     development of a social work care plan
              2.     Social work plan follow-up, appropriate intervention and referrals
              Maximum: 6 units per pregnancy

        F.    Early Discharge Home Visit

              If a physician or certified nurse-midwife chooses to discharge a low-risk mother and
              newborn from the hospital early (less than 24 hours after delivery), the physician or
              certified nurse-midwife may provide a home visit to the mother and baby within 72 hours of
              the hospital discharge. The physician or certified nurse-midwife may request an early
              discharge home visit from any clinic that provides perinatal services. Visits will be done by
              the physician or certified nurse-midwife’s order (includes a hospital discharge order).

              A home visit may be ordered for the mother and/or infant discharged later than 24 hours if
              there is specific medical reason for home follow-up.

              Billing instructions and procedure codes may be found in Section 252.450.

    214.630          Fetal Non-Stress Test                                                            7-1-05

        The fetal non-stress test is limited to 2 per pregnancy per recipient. If it is necessary to exceed
        this limit, the nurse practitioner must request an extension of benefits and submit documentation
        that establishes medical necessity. Refer to Section 214.900 of this manual for procedures to
        request extension of benefits. Refer to Section 252.451 of this manual for billing instructions
        and the procedure code.

        The post-procedural visits are covered within the 10-day period following the fetal non-stress
        test.

    214.700          Hospital Services

                                                                                                      Section II-18
Nurse Practitioner                                                                                     Section II


    214.710          Inpatient Services                                                           10-13-03

        Nurse practitioner inpatient services must meet the Medicaid requirement of medical necessity.
        The Quality Improvement Organization (QIO) will deny payments for inpatient admissions and
        subsequent inpatient services when they determine that inpatient care was not necessary.
        Inpatient services are subject to QIO review for medical necessity whether the nurse practitioner
        admitted the patient, or whether Medicaid deemed the inpatient status criteria in Section
        214.711.

        The attending nurse practitioner must document the medical necessity of admitting a patient to
        observation status, whether the patient’s condition is emergent or non-emergent. Nurse
        practitioner and hospital claims for hospital observation services are subject to post-payment
        review to verify medical necessity.

    214.711          Medicaid Utilization Management Program (MUMP)                                 4-1-07

        The Medicaid Utilization Management Program (MUMP) determines covered lengths of stay in
        inpatient acute care and/or general hospitals, in state and out of state.

        Length-of-stay determinations are made by the Quality Improvement Organization (QIO),
        Arkansas Foundation for Medical Care, Inc., (AFMC) under contract to the Arkansas Medicaid
        Program.

        Individuals in all Medicaid eligibility categories and all age groups, except beneficiaries under
        age one (1), are subject to this policy. Medicaid beneficiaries under age one (1) at the time of
        admission are exempt from the MUMP policy for dates of service before their first birthday.
        Refer to item ―E‖ below for the procedure to follow when a child’s first birthday occurs during an
        inpatient stay.

        The procedures for the MUMP are as follows:
        A.    Medicaid will reimburse hospitals for up to four (4) days of inpatient service with no pre-
              certification requirement, except for admissions by transfer from another hospital.

        B.    If the attending nurse practitioner determines the patient should not be discharged by the
              fifth day of hospitalization, a hospital medical staff member may contact AFMC and
              request an extension of inpatient days. The following information is required:
              1.     Patient name and address (including zip code)
              2.     Patient birth date
              3.     Patient Medicaid number
              4.     Admission date
              5.     Hospital name
              6.     Hospital provider identification number
              7.     Attending nurse practitioner provider identification number
              8.     Principal diagnosis
              9.     Surgical procedures performed or planned
              10.    The number of days being requested for continued inpatient care
              11.    All available medical information justifying or supporting the necessity of continued
                     stay in the hospital
        C.    Contact AFMC for procedure pre-certification or length of stay review. View or print
              AFMC contact information.

                                                                                                    Section II-19
Nurse Practitioner                                                                                         Section II

        D.    AFMC will base the number of days allowed for an extension on their medical judgment
              utilizing Medicaid guidelines.

        E.    When a Medicaid beneficiary reaches age one (1) during an inpatient stay, the days from
              the admission date through the day before the patient’s birthday are exempt from the
              MUMP policy. MUMP policy becomes effective on the one-year birthday. The patient’s
              birthday is the first day of the four days not requiring MUMP certification. If the stay
              continues beyond the fourth day (inclusive) of the patient’s first birthday, hospital staff must
              apply for MUMP certification of the additional days.

        F.    Additional extensions may be requested as needed.

        G.    AFMC assigns an authorization number to an approved extension request and sends
              written notification to the hospital.

        H.    Reconsideration reviews of denied extensions may be requested by sending the medical
              record to AFMC through regular mail, or expedited by overnight express. The hospital will
              be notified by the next working day of the decision.

        I.    Calls for extension of days may be made at any point from the fourth day of stay through
              discharge. However, the provider must accept the financial liability should the stay not
              meet the necessary medical criteria for inpatient services. If the provider chooses to delay
              calling for extension verification and the services are denied based on medical necessity,
              the beneficiary may not be held liable. All calls will be limited to 10 minutes to allow equal
              access to all providers.

        J.    If the fifth day of an admission falls on a Saturday, Sunday or holiday, it is recommended
              that the hospital provider call for an extension prior to the fifth day if the nurse practitioner
              has recommended a continued stay.

        K.    Inpatient stays for bone marrow, liver, heart, lung, skin and pancreas and/or kidney
              transplant procedures are excluded from this review program.

        L.    A retrospective or post-payment random sample review will be conducted for all
              admissions, including inpatient stays of four days or less, to ensure that medical necessity
              for the services is substantiated.

        M.    Admissions of retroactive eligible beneficiary: If eligibility is identified while the patient is
              still an inpatient, the hospital may call for retrospective review of those days already used
              past the original four for a determination of post-authorization and concurrent evaluation of
              future extended days.

              If the retroactive eligible beneficiary is not identified until after discharge, and the hospital
              files a claim and receives a denial for any days past the original four allowed, the hospital
              may call for post-extension evaluation approval of the denied days. If granted, the claim
              may be refiled. If the length of stay is more than 30 days, the provider may submit the
              entire medical record to AFMC to review.

        N.    Claims submitted without calling for an extension request will result in automatic denials of
              any days billed beyond the fourth day. The only exceptions are for claims reflecting third
              party liability and patients with retroactive Medicaid eligibility described in items I and M
              above.

        O.    If a patient is transferred from one facility to another, the receiving facility must contact
              AFMC within 24 hours of admitting the patient to qualify the inpatient stay. If an admission
              falls on a weekend or holiday, the provider may contact AFMC on the first working day
              following the weekend or holiday.



                                                                                                        Section II-20
Nurse Practitioner                                                                                        Section II

        P.    The certification process for extensions of inpatient days described in this section is a
              separate requirement from the prior authorization process. If a procedure requires prior
              authorization, the provider must request and receive prior authorization for the procedure
              code in order to be reimbursed.

        Q.    If a provider fails to contact AFMC for an extension of inpatient days due to the patient’s
              having private insurance or Medicare Part A and later receives a denial due to non-
              covered service, lost eligibility, benefits exhausted, etc., post-certification of days past the
              original four days may be obtained by the following procedures:
              1.     Send a copy of the denial notice received from the third party payer to AFMC,
                     attention Pre-certification Supervisor.
              2.     Include a note requesting post-certification and the full name of the requester and a
                     phone number where the requester may be reached.
                     Upon receipt of the denial copy and the provider request, an AFMC coordinator will
                     call the provider and obtain certification information.
        R.    If a third party insurer pays for an approved number of days, Medicaid will not grant an
              extension for days beyond the number of days approved by the private insurer.

    214.712          Evaluation and Management                                                      10-13-03

        A.    Medicaid covers nurse practitioner evaluation and management services for hospital
              inpatients on Medicaid-covered inpatient days only. The single exception to this policy is
              that Medicaid will cover discharge day management. Medicaid does not remit the
              hospitals per diem for the day of discharge unless it is also the admission day. Medicaid
              reimburses nurse practitioners for medically necessary discharge day management unless
              the nurse practitioner evaluation and management services for that day are included in
              another service, or unless the nurse practitioner does not customarily bill private-pay
              patients for discharge day management.

        B.    The Medicaid Program covers only one evaluation and management service per day,
              regardless of how many times the nurse practitioner sees the patient.

        C.    The Medicaid Program covers standby or detention services when requested by a
              physician that involves prolonged attendance without direct (face-to-face) patient contact.
              When providing standby services, the nurse practitioner must not be providing care or
              services to other patients during this period. Service is covered when provided in the
              inpatient hospital setting and is limited to one unit per date of service.

        D.    The Medicaid Program will recover payments to nurse practitioners for inpatient evaluation
              and management services on days for which the hospital’s inpatient claims are denied (or
              would be denied, if filed) for:
              1.     Exceeding benefit limits,
              2.     Failure to pre-certify inpatient days, when applicable, or
              3.     Lack of medical necessity.

    214.713          Professional Components of Diagnostic and Therapeutic                          10-13-03
                     Procedures

        Medicaid reimbursement to hospitals for inpatient services includes the non-professional
        components (technical components) such as machine tests, laboratory tests and radiology
        procedures provided to inpatients.




                                                                                                       Section II-21
Nurse Practitioner                                                                                      Section II

        Reimbursement to nurse practitioners and independent laboratories for laboratory and radiology
        services for inpatients is solely for the professional component of machine tests, radiology
        services and anatomical laboratory services.

        Medicaid does not pay for technical components of diagnostic procedures (or complete
        procedures that include a technical component) or for clinical laboratory procedures performed
        in the course of diagnosing and treating a hospital inpatient. Hospitals must furnish or purchase
        those ancillary services.

    214.714          Inpatient Hospital Benefit Limits                                             10-13-03

        A.    There is an annual benefit limit of 24 medically necessary days per state fiscal year (July 1
              through June 30) for Medicaid recipients ages 21 and older.

        B.    There is no inpatient hospital benefit limit for recipients under age 21 in the Child Health
              Services (EPSDT) Program.

    214.720          Outpatient Hospital Services                                                  10-13-03

        For the purpose of coverage and reimbursement determination, outpatient hospital nurse
        practitioner services are divided into two types of service.

    214.721          Emergency Services                                                            10-13-03

        Nurse practitioner outpatient hospital visits are covered as an emergency when the recipient’s
        medical condition constitutes an emergency medical condition. (Refer to the Glossary of this
        manual for the definition of emergency services.)

        Services not considered as emergency services are covered with primary care physician
        approval, or the recipient may be billed for the services.

    214.722          Non-Emergency Services                                                        10-13-03

        Coverage of non-emergency nurse practitioner services in an outpatient hospital setting is
        restricted to a visit charge and the professional component for machine tests, radiology and
        anatomical laboratory procedures.

    214.800          Occupational, Physical and Speech Therapy                                       1-1-09

        A.    Medicaid covers occupational, physical, and speech therapy services for eligible
              beneficiaries under age 21 in the Child Health Services (EPSDT) Program by qualified
              occupational, physical or speech therapy providers. Therapy services are not covered as
              nurse practitioner services. The following is provided for the nurse practitioner’s
              information.

        B.    Speech therapy services ONLY are covered for beneficiaries in the ARKids First-B
              program benefits.

        C.    Therapy services for individuals age 21 and older are only covered when provided through
              the following Medicaid Programs: Developmental Day Treatment Clinic Services
              (DDTCS), Hospital/Critical Access Hospital (CAH), Rehabilitative Hospital, Home Health,
              Hospice and Physician. Refer to these Medicaid provider manuals for conditions of
              coverage and benefit limits.

        D.    All therapy services for beneficiaries under age 21 require a referral for evaluation utilizing
              the form DMS-640 and a separate form DMS-640 for the written prescription from the
              patient’s primary care physician (PCP) or attending physician if the beneficiary is exempt
              from PCP Managed Care Program requirements. A referral for therapy services must be

                                                                                                     Section II-22
Nurse Practitioner                                                                                       Section II

              renewed every six months. After the initial referral using the form DMS-640 and initial
              prescription, utilizing a separate form DMS-640, subsequent referrals and prescriptions for
              continued therapy may be made at the same time using the same DMS-640. The
              prescription for treatment is valid for one year unless the prescribing physician specifies a
              shorter period.

        E.    The PCP or attending physician must complete and sign the DMS-640 for beneficiaries
              under age 21. The PCP or attending physician must initiate a referral and prescription for
              beneficiaries over age 21. An original signature is required when making a referral or
              prescribing a therapy service. An electronic signature is acceptable on either document,
              provided it is in compliance with Arkansas Code 25-31-103. A copy of the prescription
              must be maintained in the beneficiary’s records. The original prescription is to be
              maintained by the physician. View or print form DMS-640 (for beneficiaries under age
              21)

        F.    Medicaid will reimburse up to four (4) occupational, physical and speech therapy
              evaluation units (1 unit = 30 minutes) per discipline, for an eligible beneficiary per state
              fiscal year (July 1 through June 30) without authorization.

              Medicaid will reimburse up to four (4) occupational, physical and speech therapy units (1
              unit = 15 minutes) daily, per discipline, for an eligible beneficiary without authorization.

              Extended therapy services may be provided based on medical necessity, for Medicaid
              beneficiaries under age 21.

              Occupational, physical and speech therapies are subject to the benefit limit of
              12 outpatient hospital visits per state fiscal year (SFY) for beneficiaries age 21 and over.
              Benefit Extensions may be provided for therapy services, based on medical necessity, for
              Medicaid beneficiaries 21 years of age and over when provided within a covered program.

    214.810          Occupational, Physical and Speech Therapy Guidelines for                       11-1-10
                     Retrospective Review

        Though nurse practitioners are not reimbursed for occupational, physical and speech therapy
        services, it is important for the nurse practitioner to be aware of Medicaid’s guidelines to
        document medical necessity. For Arkansas Medicaid guidelines applicable to therapy services,
        please refer to the Occupational, Physical and Speech Therapy Services provider manual.

    214.811          Occupational and Physical Therapy Guidelines                                     3-1-05

        Occupational, physical and speech therapists must adhere to the specific guidelines for
        retrospective review.
        A.    Therapy services for individuals must be medically necessary to the treatment of the
              individual’s medical condition as prescribed by the individual’s PCP. Nurse practitioners
              are not reimbursed for occupational or physical therapy services.
              1.     The services must be considered under accepted standards of practice to be a
                     specific and effective treatment for the patient’s condition.
              2.     The services must be of such a level of complexity, or the patient’s condition must be
                     such that the services required can be safely and effectively performed only by or
                     under the supervision of a qualified physical therapist.
              3.     There must be reasonable expectation that therapy will result in a meaningful
                     improvement or a reasonable expectation that therapy will prevent a worsening of
                     the condition (See medical necessity definition in the Glossary of this manual).
              A diagnosis alone is not sufficient documentation to support the medical necessity of
              therapy. Assessment for physical therapy includes a comprehensive evaluation of the
                                                                                                      Section II-23
Nurse Practitioner                                                                                        Section II

              patient’s physical deficits and functional limitations, treatment planned and goals to
              address each identified problem.

        B.    Frequency, Intensity and Duration of Physical Therapy Services:

              Frequency, intensity and duration of therapy services should always be medically
              necessary and realistic for the age of the child and the severity of the deficit or disorder.
              Therapy is indicated if improvement will occur as a direct result of these services and if
              there is a potential for improvement in the form of functional gain.
              1.     Monitoring: May be used to ensure that the child is maintaining a desired skill level
                     or to assess the effectiveness and fit of equipment such as orthotics and other
                     durable medical equipment. Monitoring frequency should be based on a time
                     interval that is reasonable for the complexity of the problem being addressed.
              2.     Maintenance Therapy: Services that are performed primarily to maintain range of
                     motion or to provide positioning services for the patient do not qualify for physical
                     therapy services. These services can be provided to the child as part of a home
                     program that can be implemented by the child’s caregivers and do not necessarily
                     require the skilled services of a physical therapist to perform safely and effectively.
              3.     Duration of Services: Therapy services should be provided as long as reasonable
                     progress is made toward established goals. If reasonable functional progress
                     cannot be expected with continued therapy, then services should be discontinued
                     and monitoring or establishment of a home program should be implemented.
        C.    Progress Notes:
              1.     Child’s name.
              2.     Date of service.
              3.     Time in and time out of each therapy session.
              4.     Objectives addressed (should coincide with the plan of care).
              5.     A description of specific therapy services provided daily and the activities rendered
                     during each therapy session, along with a form measurement.
              6.     Progress notes must be legible.
              7.     Therapists must sign each date of entry with a full signature and credentials.
              8.     Graduate students must have the supervising physical therapist co-sign progress
                     notes.

    214.812          Speech-Language Therapy Retrospective Review Guidelines                          8-1-09

        A.    Speech-language therapy services must be medically necessary to the treatment of the
              individual’s illness or injury. To be considered medically necessary, the following
              conditions must be met:
              1.     The services must be considered under accepted standards of practice to be a
                     specific and effective treatment for the patient’s condition.
              2.     The services must be of such a level of complexity, or the patient’s condition must be
                     such, that the services required can be safely and effectively performed only by or
                     under the supervision of a qualified speech and language pathologist.
              3.     There must be reasonable expectation that therapy will result in meaningful
                     improvement or a reasonable expectation that therapy will prevent a worsening of
                     the condition. (See medical necessity in glossary of the Arkansas Medicaid manual.)
              A diagnosis alone is not sufficient documentation to support the medical necessity of
              therapy. Assessment for speech-language therapy includes a comprehensive evaluation
                                                                                                       Section II-24
Nurse Practitioner                                                                                      Section II

              of the patient’s speech language deficits and functional limitations, treatment planned and
              goals to address each identified problem.

        B.    Evaluations:

              In order to determine that speech-language therapy services are medically necessary, an
              evaluation must contain the following information:
              1.     Date of evaluation.
              2.     Child’s name and date of birth.
              3.     Diagnosis specific to therapy.
              4.     Background information including pertinent medical history; and, if the child is 12
                     months of age or younger, gestational age.
              5.     Standardized test results, including all subtest scores, if applicable. Test results, if
                     applicable, should be adjusted for prematurity (when less than 37 weeks gestation) if
                     the child is 12 months of age or younger this should be noted in the evaluation.
              6.     An assessment of the results of the evaluation including recommendations for
                     frequency and intensity of treatment.
              7.     The child should be tested in their native language; if not, an explanation must be
                     provided in the evaluation.
              8.     Signature and credentials of the therapist performing the evaluation.
              The mental measurement yearbook is the standard reference to determine good
              reliability/validity of the test(s) administered in the evaluation.

        C.    Birth to Three:
              1.     ― (minus) 1.5 SD (standard score of 77) below the mean in two areas (expressive,
                     receptive) or a ― (minus) 2.0 SD (standard score of 70) below the mean in one area
                     to qualify for language therapy.
              2.     Two language tests must be reported with at least one of these being a global norm-
                     referenced standardized test with good reliability/validity. The second test may be
                     criterion referenced.

    214.900          Procedures for Obtaining Extension of Benefits                                  2-1-05

        Nurse practitioners who perform laboratory and x-ray services within their scope of practice may
        request extension of benefits for those services if the patient has exhausted the benefit limit. To
        request an extension of benefits for laboratory and x-ray services, use the following procedures.

    214.910          Extension of Benefits for Laboratory and X-Ray Services                         2-1-05

        A.    Requests for extension of benefits for lab and x-ray services must be mailed to Arkansas
              Foundation for Medical Care, Inc. (AFMC), Attention EOB Review. View or print the
              Arkansas Foundation for Medical Care, Inc. contact information.
              1.     Requests for extension of benefits are considered only after a claim is filed and is
                     denied because the patient’s $500 benefit limits are exhausted.
              2.     Submit with the request a copy of the Medical Assistance Remittance and Status
                     Report reflecting the claim’s denial for exhausted benefits. Do not send a claim.
        B.    A request for extension of benefits must be received by AFMC within 90 calendar days of
              the date of benefit limit denial.
              1.     Any requests received beyond the 90-day deadline will not be considered.

                                                                                                     Section II-25
Nurse Practitioner                                                                                     Section II

              2.     AFMC will consider extending benefits in cases of medical necessity if all required
                     documentation is received timely.

    214.920          Completion of Request Form DMS-671, “Request For Extension of                  7-1-07
                     Benefits for Clinical, Outpatient, Laboratory and X-Ray Services.”

              Requests for extension of benefits for Clinical Services (Physician’s Visits), Outpatient
              Services (Hospital Outpatient visits), Laboratory Services (Lab Tests) and X-ray services
              (X-ray, Ultrasound, Electronic Monitoring - e.e.g.; e.k.g.; etc-), must be submitted to AFMC
              for consideration. Consideration of requests for extension of benefits requires correct
              completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient,
              Laboratory and X-Ray (form DMS-671). View or print form DMS-671.

              Complete instructions for accurate completion of form DMS- 671 (including
              indication of required attachments) accompany the form. All forms are listed and
              accessible in Section V of each Provider Manual.

    214.930          Documentation Requirements                                                     2-1-05

        A.    To request extension of benefits for any benefit limited service, all applicable records that
              support the medical necessity of extended benefits are required.

        B.    Documentation requirements are as follows.
              1.     Clinical records must:
                     a.   Be legible and include records supporting the specific request
                     b.   Be signed by the performing provider
                     c.   Include clinical, outpatient and/or emergency room records for dates of service
                          in chronological order
                     d.   Include related diabetic and blood pressure flow sheets
                     e.   Include a current medication list for the date of service
                     f.   Include the obstetrical record related to a current pregnancy when applicable
                     g.   Include clinical indication for laboratory and x-ray services ordered with a copy
                          of orders for laboratory and x-ray services signed by the physician
              2.     Laboratory and radiology reports must include:
                     a.   Clinical indication for laboratory and x-ray services ordered
                     b.   Signed orders for laboratory and radiology services
                     c.   Results signed by the performing provider
                     d.   Current and all previous ultrasound reports, including biophysical profiles and
                          fetal non-stress tests when applicable

    214.940          Reconsideration of Extensions of Benefits Denial                               2-1-05

        A.    Any reconsideration request for denial of extension of benefits must be received at AFMC
              within 30 days of the date of denial notice. The following information is required from
              providers requesting reconsideration of denial:
              1.     Return a copy of current NOTICE OF ACTION denial letter with re-submissions.
              2.     Return all previously submitted documentation as well as additional information for
                     reconsideration.
        B.    Only one reconsideration is allowed. Any reconsideration request that does not include
              required documentation will be automatically denied.

                                                                                                    Section II-26
Nurse Practitioner                                                                                      Section II

        C.    AFMC reserves the right to request further clinical documentation as deemed necessary to
              complete the medical review.

    214.950          Beneficiary Due Process

    214.951          Appealing an Adverse Decision                                                 3-1-05

        When the Division of Medical Services (DMS) denies a benefit extension request for laboratory
        and x-ray services, and the beneficiary wishes to appeal the denial, the beneficiary may request
        a fair hearing.

        An appeal request must be in writing and received by the Appeals and Hearings Section of the
        Department of Human Services within 30 days of the date on the letter from DMS explaining the
        denial. Appeal requests must be 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.

    214.952          Requesting Initiation or Continuation of Services Pending the                 3-1-05
                     Outcome of an Appeal

        A.    A beneficiary may request that services be continued (or that services begin, in cases
              where coverage has been denied), pending the outcome of an appeal.
              1.     Appeals that include a request to begin or continue services must be received by the
                     DHS Appeals and Hearing Section within 10 days of the date on the DMS denial
                     letter.
              2.     When such requests are made and timely received by the Appeals and Hearings
                     Section, DMS will authorize the services and notify the provider and beneficiary.
              3.     The provider will be reimbursed for services furnished under these circumstances
                     and for which the provider correctly bills Medicaid.
        B.    If the beneficiary loses the appeal, DMS will take action to recover from the beneficiary
              Medicaid’s payments for the services that were provided pending the outcome of the
              appeal.


    220.000          PRIOR AUTHORIZATION

    221.000          Procedure for Obtaining Prior Authorization                                   4-1-07

        A.    Certain medical and surgical procedures are not covered without prior authorization,
              because of federal requirements or because of the elective nature of the surgery.

        B.    Arkansas Foundation for Medical Care, Inc., (AFMC) issues prior authorizations for
              restricted medical and surgical procedures covered by the Arkansas Medicaid Program.
              1.     Prior authorization determinations are in accordance with established medical or
                     administrative criteria combined with the professional judgment of AFMC physician
                     advisors.
              2.     Payment for prior-authorized services is in accordance with federal regulations.
        C.    Written documentation is not required for prior authorization. However, the patient’s
              records must substantiate the oral information given to AFMC. Any retrospective review of
              a case will rely on the written record.




                                                                                                   Section II-27
Nurse Practitioner                                                                                         Section II

              It is the responsibility of the nurse practitioner who will perform the procedure to initiate the
              prior authorization request. The nurse practitioner or an office nurse must contact AFMC.
              View or print AFMC contact information.

        D.    The nurse practitioner or the office nurse must furnish the following specific information to
              AFMC: (ALL CALLS WILL BE TAPE RECORDED.)
              1.     Patient Name and Address
              2.     Beneficiary Medicaid Identification Number
              3.     Nurse Practitioner Name and License Number
              4.     Nurse Practitioner Provider Identification Number
              5.     Hospital Name
              6.     Date of Service for Requested Procedure
              7.     Card Issuance Date for Retroactive Eligibility Authorizations
        E.    AFMC will give approval or denial of the request by phone with follow-up in writing. If
              approved:
              1.     AFMC will assign a prior authorization control number that must be entered in the
                     appropriate field in the electronic claim format when billing for the procedure. If
                     surgery is involved, a copy of the authorization will be mailed to the hospital where
                     the service will be performed. If the hospital has not received a copy of the
                     authorization before the time of admission, the hospital will contact the admitting
                     nurse practitioner or AFMC to verify that prior authorization has been granted.
              2.     The Medicaid program will not pay for inpatient hospital services that require prior
                     authorization if the prior authorization has not been requested and approved.
              3.     Consulting professionals are responsible for calling AFMC to have their required
                     and/or restricted procedures added to the PA file. They will be given the prior
                     authorization number at the time of the call on those cases that are approved. A
                     letter verifying the PA number will be sent to the consultant upon request.
        F.    Prior authorization of service does not guarantee eligibility for a beneficiary. Payment is
              still subject to verification that the beneficiary is Medicaid-eligible at the time services are
              provided.

    221.100          Post-Procedural Authorization                                                   10-13-03

        Post-procedural authorization will be granted only for emergency procedures for recipient’s age
        21 and older. Requests for post-authorization of an emergency procedure must be applied for
        on the first working day after the procedure is performed.

        In cases of retroactive eligibility, AFMC must be contacted for post-authorization within 60 days
        of the eligibility authorization on date displayed in the electronic eligibility verification response.

    221.110          Post-Procedural Authorization Process for Recipients Under Age 21               10-13-03

        A.    Providers performing surgical procedures that require prior authorization are allowed 60
              days from the date of service to obtain a prior authorization number if the recipient is under
              age 21.

        B.    The following post-procedural authorization process must be followed when obtaining an
              authorization number.




                                                                                                        Section II-28
Nurse Practitioner                                                                                        Section II

              1.     All requests for post-procedural authorizations for eligible recipients are to be made
                     to the Arkansas Foundation for Medical Care, Inc., (AFMC). View or print AFMC
                     contact information. These calls will be tape-recorded.
              2.     Out-of-state providers and others without electronic capability may call the HP
                     Enterprise Services Provider Assistance Center to obtain the dates of eligibility.
                     View or print the HP Enterprise Services Provider Assistance Center contact
                     information.
              3.     AFMC must be given the identifying criteria for the recipient and provider and all of
                     the medical data necessary to justify the procedures. As medical information will be
                     exchanged for this procedure, the nurse practitioner or a member of his or her
                     nursing staff must make these calls.
              4.     The provider will be issued a PA number at the time of the call if the procedure
                     requested is approved. A follow-up letter will be mailed the same day to the nurse
                     practitioner.
              5.     Consultants are responsible for calling AFMC to have their required and/or restricted
                     procedures added to the PA file. They will be given the prior authorization number at
                     the time of the call on cases that are approved. A letter verifying the PA number will
                     be sent to the consultant upon request. During a call, all patient identification
                     information and medical information related to the necessity of the procedure
                     needing authorization must be provided.
              The Arkansas Medicaid Program continues to recommend that providers obtain prior
              authorization for procedures requiring authorization in order to prevent risk of denial due to
              lack of medical necessity.

    221.200          Prescription Prior Authorization                                               10-13-03

        Prescription drugs are available for reimbursement under the Arkansas Medicaid Program when
        prescribed by a nurse practitioner with prescriptive authority. Certain prescription drugs may
        require prior authorization. It is the responsibility of the prescriber to request and obtain the prior
        authorization. Refer to the Arkansas Medicaid Web site at https://www.medicaid.state.ar.us/
        for the following information:
        A.    Prescription drugs requiring prior authorization.

        B.    Criteria for drugs requiring prior authorization.

        C.    Forms to be competed for prior authorization.

        D.    Procedures required of the prescriber to request and obtain prior authorization.

    221.300          Procedures that Require Prior Authorization                                    10-13-03

        Medical and/or surgical procedures that are generally restricted to the outpatient setting no
        longer require prior authorization for inpatient services.

    222.000          Appeal Process for Medicaid Recipients                                         10-13-03

        When the Division of Medical Services denies coverage of services the recipient may request a
        fair hearing of the reconsideration decision of the denial of services from the Department of
        Human Services.

        The appeal request must be in writing and received by the Appeals and Hearings Section of the
        Department of Human Services within thirty (30) days of the date on the letter explaining the
        denial. Appeal requests must be submitted to the Department of Human Services Appeals and


                                                                                                       Section II-29
Nurse Practitioner                                                                                       Section II

        Hearings Section. View or print the Department of Human Services Appeals and Hearings
        Section contact information.


    230.000          REIMBURSEMENT

    231.000          Method of Reimbursement                                                       10-13-03

        Medicaid reimbursement for nurse practitioner services is based on the lesser of the amount
        billed or the Title XIX maximum allowable.

    232.000          Rate Appeal Process                                                           10-13-03

        A provider may request reconsideration of a program decision by writing to the Assistant
        Director, Division of Medical Services. This request must be received within 20 calendar days
        following the application of policy and/or procedure or the notification of the provider of its rate.
        Upon receipt of the request for review, the Assistant Director will determine the need for a
        program/provider conference and will contact the provider to arrange a conference if needed.
        Regardless of the program decision, the provider will be afforded the opportunity for a
        conference, if he or she so wishes, for a full explanation of the factors involved and the program
        decision. Following review of the matter, the Assistant Director will notify the provider of the
        action to be taken by the Division within 20 calendar days of receipt of the request for review or
        the date of the program/provider conference.

        If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the
        provider may then appeal the question to a standing rate review panel established by the
        Director of the Division of Medical Services. The rate review panel will include one member of
        the Division of Medical Services, a representative of the provider association and a member of
        the Department of Human Services (DHS) management staff, who will serve as chairman.

        The request for review by the rate review panel must be postmarked within 15 calendar days
        following the notification of the initial decision by the Assistant Director, Division of Medical
        Services. The rate review panel will meet to consider the question(s) within 15 calendar days
        after receipt of a request for such appeal. The question(s) will be heard by the panel and a
        recommendation will be submitted to the Director of the Division of Medical Services.


    250.000          BILLING PROCEDURES

    252.000          Introduction to Billing                                                         7-1-07

        Nurse Practitioner providers use the CMS-1500 form to bill the Arkansas Medicaid Program on
        paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges
        for only one beneficiary.

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

    252.000          CMS-1500 Billing Procedures

    252.100          Nurse Practitioner Procedure Codes                                            10-13-03

        Procedure codes listed in Sections 252.110, 252.120 and 252.130 are payable to nurse
        practitioners.

    252.110          Payable CPT Procedure Codes                                                   10-13-03



                                                                                                      Section II-30
Nurse Practitioner                                                                             Section II

        The following CPT procedure codes, as well as HCPCS procedure codes in Section 252.120
        and local procedure codes listed in Section 252.130, are payable to nurse practitioners.

         10040          10060          10120          10140          10160          11000
         11040          11055          11056          11057          11100          11101
         11200          11307          11400          11401          11402          11403
         11404          11406          11420          11421          11422          11423
         11424          11426          11440          11441          11442          11443
         11601          11602          11603          11620          11621          11622
         11623          11640          11641          11642          11643          11719
         11740          11975          11976          11977          12001          12002
         12004          12011          12013          12020          16000          16020
         16025          16030          17000          17110          17111          17340
         19000          19001          29065          29075          29105          29125
         29130          29305          29325          29345          29355          29358
         29365          29405          29425          29435          29440          29505
         29515          29520          29530          29540          29550          29580
         29590          29700          29705          29710          29715          29720
         29730          29740          29750          30300          31500          31515
         36145          36600          36620          40804          46900          46910
         46916          46922          46924          54050          54055          54056
         54150          56501          56740          57061          57065          57150
         57160          57170          57410          57452          57454          57500
         57505          57510          57511          58300          58301          59020
         59025          71010          71020          71030          72010          72020
         72040          72050          81000          81001          81002          81003
         81025          81099          82270          82274          82947          82948
         82950          82951          83020          83520          83896          84702
         84703          85014          85018          85022          85048          85610
         85660          86403          86580          86585          86592          86593
         86687          86701          87070          87075          87081          87086
         87088          87205          87207          87210          87390          87430
         87470          87490          87590          87880          90281          90283
         90287          90288          90291          90296          90371          90375
         90376          90385          90386          90389          90393          90396
         90399          90581          90585          90632          90633          90634
         90636          90645          90646          90647          90648          90657
         90658          90659          90660          90665          90669          90675

                                                                                            Section II-31
Nurse Practitioner                                                                     Section II

         90676           90690        90691           90692       90700     90701
         90702           90703        90704           90705       90706     90707
         90708           90709        90710           90712       90713     90716
         90718           90720        90721           90732       90733     90735
         90740           90743        90744           90746       90747     90748
         90749           90782        90799           90801       91123     92551
         92552           92567        92950           93000       93005     93041
         94010           94060        94070           94150       94200     94650
         94651           94760        94761           95060       95065     95115
         95117           95120        95125           95130       95131     95132
         95133           95134        95144           96400       96405     96406
         96408           96410        96412           96414       96420     96422
         96423           96425        96520           96545       96549     97601
         97602           97703        99050           99052       99054     99058
         99082           99175        99201           99202       99203     99204
         99205           99211        99212           99213       99214     99215
         99221           99222        99223           99231       99232     99233
         99238           99241        99242           99243       99244     99245
         99251           99252        99253           99254       99255     99271
         99272           99273        99274           99275       99281     99282
         99283           99284        99285           99289       99290     99291
         99292           99301        99302           99303       99311     99312
         99313           99341        99342           99343       99347     99348
         99349           99360        99401           99402       99431     99432


    252.120          Payable HCPCS Procedure Codes                                10-13-03


         11975              11976             11977           36145       58300
         58301              90371             90385           90581       90659
         90660              90669             90703           90707       90732
         90735              90748             99241           99245       99271
         99275              99401             99402           99431       A4260
         J0120              J0150             J0170           J0190       J0205
         J0207              J0210             J0256           J0270       J0280
         J0285              J0290             J0295           J0300       J0330
         J0360              J0380             J0390           J0460       J0470
         J0475              J0500             J0515           J0520       J0530

                                                                                    Section II-32
Nurse Practitioner                                      Section II

         J0540       J0550   J0560   J0570   J0580
         J0585       J0600   J0610   J0620   J0630
         J0636       J0640   J0670   J0690   J0694
         J0695       J0696   J0697   J0698   J0702
         J0704       J0710   J0713   J0715   J0720
         J0725       J0735   J0740   J0743   J0745
         J0770       J0780   J0800   J0835   J0850
         J0895       J0900   J0945   J0970   J1000
         J1020       J1030   J1040   J1051   J1060
         J1070       J1080   J1100   J1110   J1120
         J1160       J1165   J1170   J1180   J1190
         J1200       J1205   J1212   J1230   J1240
         J1245       J1250   J1260   J1320   J1325
         J1330       J1364   J1380   J1390   J1410
         J1435       J1436   J1440   J1441   J1455
         J1460       J1470   J1480   J1490   J1500
         J1510       J1520   J1530   J1540   J1550
         J1560       J1563   J1564   J1570   J1580
         J1610       J1620   J1626   J1630   J1631
         J1642       J1644   J1645   J1650   J1670
         J1700       J1710   J1720   J1730   J1742
         J1750       J1785   J1790   J1800   J1810
         J1815       J1825   J1830   J1840   J1850
         J1885       J1890   J1910   J1940   J1950
         J1955       J1960   J1980   J1990   J2000
         J2010       J2060   J2150   J2175   J2180
         J2210       J2250   J2260   J2270   J2275
         J2300       J2310   J2320   J2321   J2322
         J2360       J2370   J2400   J2510   J2515
         J2540       J2550   J2560   J2590   J2597
         J2650       J2670   J2680   J2690   J2700
         J2710       J2720   J2725   J2730   J2760
         J2765       J2788   J2790   J2800   J2820
         J2910       J2912   J2916   J2920   J2930
         J2950       J2995   J3000   J3010   J3030
         J3070       J3105   J3120   J3130   J3140


                                                     Section II-33
Nurse Practitioner                                                    Section II

         J3150              J3230          J3240   J3250   J3260
         J3265              J3280          J3301   J3302   J3303
         J3305              J3310          J3320   J3350   J3360
         J3364              J3365          J3370   J3400   J3410
         J3420              J3430          J3470   J3475   J3480
         J3490              J3520          J7190   J7191   J7192
         J7194              J7197          J7199   J7300   J7310
         J7501              J7504          J7505   J7506   J7507
         J7508              J7509          J7510   J7599   J9000
         J9015              J9020          J9031   J9040   J9045
         J9050              J9060          J9062   J9065   J9070
         J9080              J9090          J9091   J9092   J9093
         J9094              J9095          J9096   J9100   J9110
         J9120              J9130          J9140   J9150   J9165
         J9170              J9181          J9182   J9190   J9200
         J9201              J9202          J9206   J9208   J9209
         J9211              J9212          J9213   J9214   J9215
         J9216              J9217          J9218   J9230   J9245
         J9250              J9260          J9265   J9266   J9268
         J9270              J9280          J9290   J9291   J9293
         J9320              J9340          J9355   J9360   J9370
         J9375              J9380          J9390   J9600   J9999
         P9041              P9045          P9046   P9047   P9612
         Q0163              Q0164          Q0165   Q0166   Q0167
         Q0168              Q0169          Q0170   Q0171   Q0172
         Q0173              Q0174          Q0175   Q0176   Q0177
         Q0178              Q0179          Q0180   Q0187   Q9920
         Q9921              Q9922          Q9923   Q9924   Q9925
         Q9926              Q9927          Q9928   Q9930   Q9931
         Q9932              Q9933          Q9934   Q9935   Q9936
         Q9937              Q9938          Q9939   Q9940   S0108
         S0177              S0179          S0187   S0612   T1015
         T1016


    252.130          Payable Local Codes                           7-1-07




                                                                   Section II-34
Nurse Practitioner                                                                               Section II

         National    Required   Local
         Code        Modifier   Code    Local Code Description
         T1015       —          Z0636   Procedure code T1015 (Z0636) should be billed for a
                                        non-emergency nurse practitioner visit.
         J7300       FP         Z0849   Supply of Intrauterine Device
         99402       SA, U1     Z1202   Risk Assessment
         99402       SA, U4     Z1203   Case Management Services, low-risk case
         99402       SA, U5     Z1204   Case Management Services, high-risk case
         99402       SA         Z1205   Perinatal Education
         99402       SB, U3     Z1206   Social Work Consultation
         99402       SA, U2     Z1207   Nutrition Consultation – Individual
         A4260       FP         Z1754   Norplant System (Complete Kit)
         90371       U1         Z1757   Hepatitis B Immune Serum Globulin (ISG) (One unit
                                        equals 1/2 cc with a maximum of 10 units billable per
                                        day.) (Payable for eligible Medicaid beneficiaries of all
                                        ages in the physician’s office, nurse practitioner’s office,
                                        outpatient hospital or dialysis facility.)
         S0179       52         Z1835   Megestrol Acetate tablet, 320 mg
         S0187       —          Z1848   Tamoxifin tablet, 10 mg
         J9045       —          Z1849   Carboplatin, 150 mg
         J9045       —          Z1850   Carboplatin, 450 mg
         S0108       —          Z1851   Mercaptopurine tablet, 50 mg
         S0177       —          Z1855   Levamisole tablet, 50 mg
         J8530       —          Z1869   Cyclophosphamide tablet, 25 mg
         J8530       —          Z1870   Cyclophosphamide tablet, 50 mg
         J2820       —          Z1871   GM-CSF 250mcg (sargramostim) Vial
         J2820       —          Z1884   Prokine 500 mcg
         36145       —          Z1913   Routine venipuncture for collection of specimen(s)
                                        (36145/Z1913 is covered only when the specimen is to
                                        be sent to a reference lab for tests. Reimbursement for
                                        collection is included in the reimbursement for lab tests
                                        when the practitioner or clinic that draws the blood does
                                        the tests.)
         J0697       —          Z1931   Zinacef, 375 mg
         Q0166       —          Z2262   Granisetron hydrochloride, oral form
         Bill on     —          Z2268   Doxorubicin HCL Lipsome (Doxil) 20 mg 10 mcc
         paper
         11975       FP         Z2294   Implantation of Contraceptive Capsules
         11976       FP         Z2295   Removal of Contraceptive Capsules
         11977       FP         Z2296   Removal and Reinsertion of Contraceptive Capsules
         58300       FP         Z2297   Insertion of Intrauterine Device


                                                                                              Section II-35
Nurse Practitioner                                                                                  Section II

         National     Required      Local
         Code         Modifier      Code     Local Code Description
         58301        FP            Z2298    Removal of Intrauterine Device
         99402        SA, FP        Z2299    Basic Family Planning Visit
         99401        FP, SA        Z2300    Periodic Family Planning Visit
         S0612        FP, TS,       Z2302    Annual Post-Sterilization Visit
                      SA
         J2788        —             Z2501    Rho (D) immune globulin, injection, human, one pre-
                                             filled single dose syringe, 50 mcg, MICRhoGAM.
                                             (Limited to one per pregnancy.)
         90707        U1            Z2633    Maternal Measles/Mumps/Rubella (MMR) (Payable
                                             when provided to women of childbearing age, ages 21
                                             through 44, who may be at risk of exposure to these
                                             illnesses. Coverage is limited to two (2) injections per
                                             lifetime.)
         90669        —             Z2691    Prevnar™ vaccine (pneumoccal 7-valent), pediatric
                                             (This vaccine should be given in four doses at 2, 4, 6
                                             and 12 to 15 months of age. Older children ages 24 to
                                             59 months may receive the vaccine if they have special
                                             health conditions. Reimbursement is for administration
                                             only.)


        NOTE: Where both a national code and a local code (“Z code”) are available, the local
              code can be used only for dates of service through October 15, 2003; the national
              code must be used for both electronic and paper claims for dates of service after
              October 15, 2003. Where only a local code is available, it can be used indefinitely,
              but it can be billed only on a paper claim. Where only a national code is
              available, it can be used indefinitely for both electronic and paper claims.

    252.200          National Place of Service (POS) Codes

    252.210          National Place of Service (POS) Codes                                       7-1-07

        Electronic and paper claims now require the same National Place of Service code.

         Place of Service                               POS Codes
         Inpatient Hospital                             21
         Outpatient Hospital                            22
         Office                                         11
         Patient’s Home                                 12
         Day Care Facility                              99
         Nursing Facility                               32
         Skilled Nursing Facility                       31
         Ambulance                                      41
         Other Locations                                99


                                                                                                 Section II-36
Nurse Practitioner                                                                                           Section II


    252.300           Billing Instructions – Paper Claims Only                                              7-1-07

        HP Enterprise Services offers providers several options for electronic billing. Therefore, claims
        submitted on paper are lower priority and are paid once a month. The only claims exempt from
        this rule are those that require attachments or manual pricing.

        Bill Medicaid for nurse practitioner services with form CMS-1500. The numbered items in the
        following instructions correspond to the numbered fields on the claim form. View a sample form
        CMS-1500.

        Carefully follow these instructions to help HP Enterprise Services efficiently process claims.
        Accuracy, completeness, and clarity are essential. Claims cannot be processed if necessary
        information is omitted.

        Forward completed claim forms to the HP Enterprise Services Claims Department. View or
        print the HP Enterprise Services Claims Department contact information

        NOTE: A provider delivering services without verifying beneficiary eligibility for each
              date of service does so at the risk of not being reimbursed for the services.

    252.310           Completion of CMS-1500 Claim Form                                                5-1-08


         Field Name and Number                    Instructions for Completion
         1.    (type of coverage)                 Not required.
         1a. INSURED’S I.D. NUMBER                Beneficiary’s or participant’s 10-digit Medicaid or
             (For Program in Item 1)              ARKids First-A or ARKids First-B identification
                                                  number.
         2.    PATIENT’S NAME (Last               Beneficiary’s or participant’s last name and first
               Name, First Name, Middle           name.
               Initial)
         3.    PATIENT’S BIRTH DATE               Beneficiary’s or participant’s date of birth as given on
                                                  the individual’s Medicaid or ARKids First-A or ARKids
                                                  First-B identification card. Format: MM/DD/YY.
               SEX                                Check M for male or F for female.
         4.    INSURED’S NAME (Last               Required if insurance affects this claim. Insured’s last
               Name, First Name, Middle           name, first name, and middle initial.
               Initial)
         5.    PATIENT’S ADDRESS (No.,            Optional. Beneficiary’s or participant’s complete
               Street)                            mailing address (street address or post office box).
               CITY                               Name of the city in which the beneficiary or
                                                  participant resides.
               STATE                              Two-letter postal code for the state in which the
                                                  beneficiary or participant resides.
               ZIP CODE                           Five-digit zip code; nine digits for post office box.
               TELEPHONE (Include Area            The beneficiary’s or participant’s telephone number
               Code)                              or the number of a reliable message/contact/
                                                  emergency telephone.
         6.    PATIENT RELATIONSHIP TO            If insurance affects this claim, check the box
               INSURED                            indicating the patient’s relationship to the insured.


                                                                                                          Section II-37
Nurse Practitioner                                                                                 Section II

         Field Name and Number               Instructions for Completion
         7.    INSURED’S ADDRESS (No.,       Required if insured’s address is different from the
               Street)                       patient’s address.
               CITY
               STATE
               ZIP CODE
               TELEPHONE (Include Area
               Code)
         8.    PATIENT STATUS                Not required.

         9.    OTHER INSURED’S NAME          If patient has other insurance coverage as indicated
               (Last name, First Name,       in Field 11d, the other insured’s last name, first
               Middle Initial)               name, and middle initial.

               a.     OTHER INSURED’S        Policy and/or group number of the insured individual.
                      POLICY OR GROUP
                      NUMBER
               b.     OTHER INSURED’S        Not required.
                      DATE OF BIRTH
                      SEX                    Not required.
               c.     EMPLOYER’S NAME OR     Required when items 9 a-d are required. Name of the
                      SCHOOL NAME            insured individual’s employer and/or school.
               d.     INSURANCE PLAN         Name of the insurance company.
                      NAME OR PROGRAM
                      NAME
         10. IS PATIENT’S CONDITION
             RELATED TO:
               a.     EMPLOYMENT? (Current   Check YES or NO.
                      or Previous)
               b.     AUTO ACCIDENT?         Required when an auto accident is related to the
                                             services. Check YES or NO.
                      PLACE (State)          If 10b is YES, the two-letter postal abbreviation for
                                             the state in which the automobile accident took place.
               c.     OTHER ACCIDENT?        Required when an accident other than automobile is
                                             related to the services. Check YES or NO.
               10d. RESERVED FOR LOCAL       Not used.
                    USE
         11. INSURED’S POLICY GROUP          Not required when Medicaid is the only payer.
             OR FECA NUMBER
               a.     INSURED’S DATE OF      Not required.
                      BIRTH
                      SEX                    Not required.
               b.     EMPLOYER’S NAME OR     Not required.
                      SCHOOL NAME




                                                                                                Section II-38
Nurse Practitioner                                                                                 Section II

         Field Name and Number              Instructions for Completion
               c.    INSURANCE PLAN         Not required.
                     NAME OR PROGRAM
                     NAME
               d.    IS THERE ANOTHER       When private or other insurance may or will cover
                     HEALTH BENEFIT         any of the services, check YES and complete items
                     PLAN?                  9a through 9d.
         12. PATIENT’S OR AUTHORIZED        Not required.
             PERSON’S SIGNATURE
         13. INSURED’S OR                   Not required.
             AUTHORIZED PERSON’S
             SIGNATURE
         14. DATE OF CURRENT:               Required when services furnished are related to an
                                            accident, whether the accident is recent or in the
               ILLNESS (First symptom) OR
                                            past. Date of the accident.
               INJURY (Accident) OR
               PREGNANCY (LMP)
         15. IF PATIENT HAS HAD SAME        Not required.
             OR SIMILAR ILLNESS, GIVE
             FIRST DATE
         16. DATES PATIENT UNABLE           Not required.
             TO WORK IN CURRENT
             OCCUPATION
         17. NAME OF REFERRING              Name and title of referral source, whether an
             PROVIDER OR OTHER              individual (such as a PCP) or a clinic or other facility.
             SOURCE
         17a. (blank)                       The 9-digit Arkansas Medicaid provider ID number of
                                            the referring physician.
         17b. NPI                           Not required.
         18. HOSPITALIZATION DATES          When the serving/billing provider’s services charged
             RELATED TO CURRENT             on this claim are related to a beneficiary’s or
             SERVICES                       participant’s inpatient hospitalization, enter the
                                            individual’s admission and discharge dates. Format:
                                            MM/DD/YY.
         19.   RESERVED FOR LOCAL           Not applicable to Nurse Practitioner services.
               USE
         20. OUTSIDE LAB?                   Not required.
               $ CHARGES                    Not required.
         21. DIAGNOSIS OR NATURE OF         Diagnosis code for the primary medical condition for
             ILLNESS OR INJURY              which services are being billed. Up to three additional
                                            diagnosis codes can be listed in this field for
                                            information or documentation purposes. Use the
                                            International Classification of Diseases, Ninth
                                            Revision (ICD-9-CM) diagnosis coding current as of
                                            the date of service from ICD-9-CM.
         22. MEDICAID RESUBMISSION          Reserved for future use.
             CODE
               ORIGINAL REF. NO.            Reserved for future use.

                                                                                                Section II-39
Nurse Practitioner                                                                               Section II

         Field Name and Number            Instructions for Completion
         23. PRIOR AUTHORIZATION          The prior authorization or benefit extension control
             NUMBER                       number if applicable.
         24A.        DATE(S) OF SERVICE   The ―from‖ and ―to‖ dates of service for each billed
                                          service. Format: MM/DD/YY.
                                          1. On a single claim detail (one charge on one line),
                                             bill only for services provided within a single
                                             calendar month.
                                          2. Some providers may bill on the same claim detail
                                             for two or more sequential dates of service within
                                             the same calendar month when the provider
                                             furnished equal amounts of the service on each
                                             day of the date sequence.
                B.   PLACE OF SERVICE     Enter the appropriate place of service code. See
                                          Section 252.200 for codes.
                C.   EMG                  Not required.
                D.   PROCEDURES,
                     SERVICES, OR
                     SUPPLIES
                     CPT/HCPCS            Enter the correct CPT or HCPCS procedure code
                                          from Sections 252.100 through 252.130.
                     MODIFIER             Modifier(s) if applicable.
                E.   DIAGNOSIS POINTER    Enter in each detail the single number—1, 2, 3, or
                                          4—that corresponds to a diagnosis code in Item 21
                                          (numbered 1, 2, 3, or 4) and that supports most
                                          definitively the medical necessity of the service(s)
                                          identified and charged in that detail. Enter only one
                                          number in E of each detail. Each DIAGNOSIS
                                          POINTER number must be only a 1, 2, 3, or 4, and it
                                          must be the only character in that field.
                F.   $ CHARGES            The full charge for the service(s) totaled in the detail.
                                          This charge must be the usual charge to any client,
                                          patient, or other beneficiary of the provider’s services.
                G.   DAYS OR UNITS        The units (in whole numbers) of service(s) provided
                                          during the period indicated in Field 24A of the detail. .
                H.   EPSDT/Family Plan    Enter E if the services resulted from a Child Health
                                          Services (EPSDT) screening/referral.
                I.   ID QUAL              Not required.
                J.   RENDERING            The 9-digit Arkansas Medicaid provider ID number of
                     PROVIDER ID #        the individual who furnished the services billed for in
                                          the detail.
                     NPI                  Not required.
         25. FEDERAL TAX I.D. NUMBER      Not required. This information is carried in the
                                          provider’s Medicaid file. If it changes, please contact
                                          Provider Enrollment.




                                                                                              Section II-40
Nurse Practitioner                                                                                          Section II

         Field Name and Number                    Instructions for Completion
         26. PATIENT’S ACCOUNT N O.               Optional entry that may be used for accounting
                                                  purposes; use up to 16 numeric or alphabetic
                                                  characters. This number appears on the Remittance
                                                  Advice as ―MRN.‖
         27. ACCEPT ASSIGNMENT?                   Not required. Assignment is automatically accepted
                                                  by the provider when billing Medicaid.
         28. TOTAL CHARGE                         Total of Column 24F—the sum all charges on the
                                                  claim.
         29. AMOUNT PAID                          Enter the total of payments previously received on
                                                  this claim. Do not include amounts previously paid by
                                                  Medicaid. *Do not include in this total the
                                                  automatically deducted Medicaid or ARKids First-B
                                                  co-payments.
         30. BALANCE DUE                          From the total charge, subtract amounts received
                                                  from other sources and enter the result.
         31. SIGNATURE OF PHYSICIAN               The provider or designated authorized individual
             OR SUPPLIER INCLUDING                must sign and date the claim certifying that the
             DEGREES OR                           services were personally rendered by the provider or
             CREDENTIALS                          under the provider’s direction. ―Provider’s signature‖
                                                  is defined as the provider’s actual signature, a rubber
                                                  stamp of the provider’s signature, an automated
                                                  signature, a typewritten signature, or the signature of
                                                  an individual authorized by the provider rendering the
                                                  service. The name of a clinic or group is not
                                                  acceptable.
         32. SERVICE FACILITY                     If other than home or office, enter the name and
             LOCATION INFORMATION                 street, city, state, and zip code of the facility where
                                                  services were performed.
               a. (blank)                         Not required.
               b. (blank)                         Not required.
         33. BILLING PROVIDER INFO &              Billing provider’s name and complete address.
             PH #                                 Telephone number is requested but not required.
               a. (blank)                         Not required.
               b. (blank)                         Enter the 9-digit Arkansas Medicaid provider ID
                                                  number of the billing provider.


    252.400          Special Billing Procedures

    252.410          Clinic or Group Billing                                                          4-1-07

        Providers who wish to have payment made to a group practice or clinic must enroll as a group
        practice. When billing, enter the Clinic/Group pay-to Provider Identification Number in Field 33
        after ―GRP#.‖ Enter the performing provider identification number in Field 24K. If more than
        one nurse practitioner in a group practice provides services for a beneficiary, the clinic may bill
        for all their services on the same claim limited only by the size of the claim format.

        Procedure code 99360 is payable when provided in the inpatient hospital setting by a nurse
        practitioner.

                                                                                                       Section II-41
Nurse Practitioner                                                                                     Section II


    252.420          Evaluations and Management

    252.421          Initial Visit                                                                10-13-03

        The American Medical Association’s Current Procedures Terminology (CPT) codes should be
        used only for the first visit of a new patient. Each subsequent visit should be billed using an
        established patient code. A distinction is made in CPT codes for new or established patients for
        office visits, home visits, nursing facility visits and emergency room visits. Refer to the latest
        edition of the CPT.

        Providers are allowed to bill one new patient visit procedure code per recipient, per attending
        provider in a three (3) year period.

    252.422          Detention Time (Standby Service)                                             10-13-03

        Procedure code 99360 must be used by nurse practitioners when billing for detention time.

        One unit equals 30 minutes. A maximum of 1 unit per date of service may be billed.

        Procedure code 99360 is payable when provided in the inpatient hospital setting by a nurse
        practitioner.

    252.423          Inpatient Hospital Visits                                                    10-13-03

        Each nurse practitioner is limited to billing one day of care for each inpatient hospital covered
        days, regardless of the number of hospital visits rendered.

    252.424          Hospital Discharge Day Management                                            10-13-03

        Procedure code 99238, hospital discharge day management, may not be billed by providers on
        the same date of service as an initial or subsequent hospital care code, procedures 99221
        through 99233. Initial hospital care codes and subsequent hospital care codes may not be billed
        on the day of discharge.

    252.425          Nursing Home Visits                                                          10-13-03

        The appropriate CPT procedure codes should be used when billing for nurse practitioner visits in
        a nursing facility.

    252.426          Specimen Collections                                                         10-13-03

        The policy in regard to collection, handling and/or conveyance of specimens is:
        A.    Reimbursement will not be made for specimen handling fees.

        B.    A specimen collection fee may be allowed only in circumstances including: (1) drawing a
              blood sample through venipuncture (e.g., inserting into a vein a needle with syringe or
              vacutainer to draw the specimen); or (2) collecting a urine sample by catheterization.

        The following codes should be used when billing for specimen collection:
         P9612             P9615           36145


        NOTE: Where both a national code and a local code (“Z code”) are available, the local
              code can be used only for dates of service through October 15, 2003; the national
              code must be used for both electronic and paper claims for dates of service after

                                                                                                    Section II-42
Nurse Practitioner                                                                                    Section II

                  October 15, 2003. Where only a local code is available, it can be used indefinitely,
                  but it can be billed only on a paper claim. Where only a national code is
                  available, it can be used indefinitely for both electronic and paper claims.

    252.428          Services Not Considered a Separate Service from an Office Visit             10-13-03

        Some services (e.g., pelvic examinations, prostatic massages, removal of sutures, etc.) are not
        considered a separate service from an office visit. The charge for such services should be
        included in the office visit charge. Billing should be under the office visit procedure code that
        reflects the appropriate level of care. Procedure code 57410 should never be used for billing
        routine pelvic examinations, but should be used only when a pelvic examination is done under
        general anesthesia.

    252.429          Health Examinations for ARKids First B Recipients and Medicaid              10-13-03
                     Recipients Under Age 21

        Providers should refer to the Child Health Services (EPSDT) Provider manual and the ARKids
        First-B Provider manual for covered services and billing procedures.

    252.430          Family Planning Services Program Procedure Codes                              7-1-07

        The following table contains Family Planning Services Program procedure codes payable to
        nurse practitioners. All of the following procedure codes require a family planning diagnosis
        code in each claim detail.

         Procedur
         e Code        Required Modifiers                     Description
         A4260         FP                                     Norplant System (Complete Kit)
         J1055         FP                                     Medrozyprogesterone acetate for
                                                              contraceptive use
         J7300         FP                                     Supply of Intrauterine Device
         J7302         FP                                     Levonorgestrel-releasing intrauterine
                                                              contraceptive system
         J7303         FP                                     Contraceptive supply, hormone
                                                              containing vaginal ring
         S0612*        FP, SA, UB                             Annual Post-Sterilization Visit*
         11975         FP, SA                                 Implantation of Contraceptive Capsules
         11976         FP, SA                                 Removal of Contraceptive Capsules
         11977         FP, SA                                 Removal and Reinsertion of
                                                              Contraceptive Capsules
         36415         FP                                     Routine venipuncture for blood collection
         58300         FP,SA                                  Insertion of Intrauterine Device
         58301         FP,SA                                  Removal of Intrauterine Device
         99402         FP, SA                                 Basic Family Planning Visit
         99401         FP, SA, UA                             Periodic Family Planning Visit

        *Women in the aid category 69, FP-W, who have undergone sterilization are eligible only for this
        annual follow-up visit.


                                                                                                   Section II-43
Nurse Practitioner                                                                                   Section II


    252.431          Family Planning Services Program Laboratory Procedure Codes                  7-1-07

        When filing electronic claims or paper claims, modifier FP must be used with the procedure
        code.

         Q0111            81001           81002          81003           81025            83020
         81000            83896           84703          85014           85018            85660
         83520            86593           86687          86701           87075            87081
         86592            87210           87390          87470           87490            87590
         87088


    252.440          Injections                                                                   7-1-07

        Providers billing the Arkansas Medicaid Program for covered injections should bill the
        appropriate CPT or HCPCS procedure code for the specific injection administered. The
        procedure codes and their descriptions may be found in the CPT coding book and in this section
        of this manual.

        Unless otherwise indicated, the procedure code for the injection includes the cost of the
        drug and the administration of the injection for intramuscular or subcutaneous routes.

        This section has seven subsections providing CPT and HCPCS procedure codes along with
        special billing instructions for covered injections. Please refer to these subsections for
        information on Chemotherapy (Section 252.441), Injections with Restrictions (Section 252.442),
        Other Covered Injections (Section 252.443), Epoetin Alpha Injections for Non-ESRD Use
        (Section 252.445), Administration of Epoetin Alpha Injections for Chronic or Acute Renal Failure
        (Section 252.446), Immunizations For Beneficiaries Under 21 (Section 252.447), and Vaccines
        for Children Program (Section 252.448).

        Most of the drugs listed in these sections can be billed electronically. However, any drug
        marked with an asterisk (*) must be billed on paper with the name of the drug and dosage
        listed in the Procedures, Services, or Supplies” column, Field 24D, of the CMS-1500 claim
        form. Payment of the drug is based on the ―Red Book‖ drug price. If preferred, a copy of the
        invoice verifying the provider’s cost of the drug may be attached to the Medicaid claim form.

    252.441          Chemotherapy                                                                 7-1-07

        A.    The following procedure codes for the administration of chemotherapy agents are payable
              only if provided in a nurse practitioner’s office, place of service code―11‖. These
              procedures are not payable if performed in the inpatient or outpatient hospital setting:


               96400              96408             96414             96423             96545
               96405              96410             96420             96425             96549
               96406              96412             96422             96520


              Only one administration fee is allowed per beneficiary per date of service unless ―multiple
              sites‖ are indicated in the ―Procedures, Services, or Supplies‖ field in the CMS-1500 claim
              form. Supplies are included as part of the administration fee. The administration fee is
              not allowed when drugs are given orally.


                                                                                                  Section II-44
Nurse Practitioner                                                                                    Section II

        B.    The following is a list of covered chemotherapy agents. The HCPCS procedure codes
              must be used to bill for chemotherapy agents. Multiple units may be billed, if appropriate.
              For coverage information regarding any chemotherapy agent not listed, please contact the
              Medicaid Reimbursement Unit by calling the Communications Hotline. View or print the
              Medicaid Reimbursement Unit contact information.

              Procedure codes followed by an asterisk (*) require paper billing with
              invoice/documentation.


               J9000              J9015             J9020             J9031              J9040
               J9045              J9050             J9060             J9062              J9065
               J9070              J9080             J9090             J9091              J9092
               J9093              J9094             J9095             J9096              J9097
               J9100              J9110             J9120             J9130              J9140
               J9150              J9165             J9170             J9181              J9182
               J9190              J9200             J9201             J9202              J9208
               J9209              J9211             J9212             J9213              J9214
               J9215              J9216             J9217             J9218*             J9230
               J9245              J9250             J9260             J9265              J9266
               J9268              J9270             J9280             J9290              J9291
               J9293              J9320             J9340             J9355              J9360
               J9370              J9375             J9380             J9390              J9600
               J9999*
              *Procedure code requires paper billing.


               National
               Code              Local Code             Local Code Description
               J9045             Z1849                  Carboplatin, 150 mg
               J8530             Z1869                  Cyclophosphamide tablet, 25 mg
               J8530             Z1870                  Cyclophosphamide tablet, 50 mg


              NOTE: Where both a national code and a local code (“Z code”) are available, the
                    local code can be used only for dates of service through October 15, 2003;
                    the national code must be used for both electronic and paper claims for
                    dates of service after October 15, 2003. Where only a local code is
                    available, it can be used indefinitely, but it can be billed only on a paper
                    claim. Where only a national code is available, it can be used indefinitely for
                    both electronic and paper claims.

    252.442          Injections With Restrictions                                                10-13-03

        The following is an alphabetized list of covered drugs for recipients of all ages. However, when
        provided to a recipient age 21 or older, a diagnosis of malignant neoplasm (diagnosis range
        140.0 to 208.91) or HIV disease (diagnosis 042) must exist.


                                                                                                   Section II-45
Nurse Practitioner                                                                                  Section II

        Procedure codes followed by an asterisk (*) require paper billing with invoice/documentation.

         J0120           J0150          J0190           J0205           J0207           J0210
         J0256           J0270          J0280           J0285           J0290           J0295
         J0300           J0330          J0360           J0380           J0390           J0460
         J0470           J0475          J0500           J0515           J0520           J0530
         J0540           J0550          J0560           J0570           J0580           J0600
         J0610           J0620          J0630           J0640           J0670           J0690
         J0694           J0696          J0697           J0698           J0702           J0704
         J0710           J0713          J0715           J0720           J0725           J0730
         J0735           J0740          J0743           J0745           J0770           J0780
         J0800           J0835          J0850           J0895           J0900           J0945
         J0970           J1000          J1020           J1030           J1040           J1051
         J1060           J1070          J1080           J1094           J1100           J1110
         J1120           J1160          J1165           J1170           J1180           J1190
         J1200           J1205          J1212           J1230           J1240           J1245
         J1250           J1260          J1320           J1325           J1330           J1364
         J1380           J1390          J1410           J1435           J1436           J1440
         J1441           J1455          J1570           J1580           J1610           J1620
         J1626           J1630          J1631           J1642           J1644           J1645
         J1650           J1670          J1700           J1710           J1720           J1730
         J1742           J1750          J1785           J1790           J1800           J1810
         J1815           J1825          J1830           J1840           J1850           J1885
         J1890           J1910          J1940           J1950           J1955           J1960
         J1980           J1990          J2000           J2010           J2060           J2150
         J2175           J2180          J2210           J2250           J2270           J2275
         J2300           J2310          J2320           J2322           J2360           J2370
         J2400           J2405          J2410           J2430           J2440           J2460
         J2510           J2515          J2540           J2550           J2560           J2590
         J2597           J2650          J2670           J2680           J2690           J2700
         J2710           J2720          J2725           J2730           J2760           J2765
         J2800           J2820          J2860           J2912           J2920           J2930
         J2950           J2995          J3000           J3010           J3030           J3070
         J3105           J3120          J3130           J3140           J3150           J3230
         J3240           J3250          J3260           J3265           J3280           J3301
         J3302           J3303          J3305           J3310           J3320           J3350
         J3360           J3364          J3365           J3370           J3400           J3410


                                                                                                 Section II-46
Nurse Practitioner                                                                                       Section II

         J3430            J3470           J3475            J3480            J3490*           J3520
         J7190            J7191           J7192            J7194            J7197            J7310
         J7501            J7504           J7505            J7506            J7507            J7508
         J7509            J7510           J7599*           J9206            J9208            J9216
         J9390            P9041           P9045            P9046            P9047            Q0163
         Q0164            Q0165           Q0166            Q0167            Q0168            Q0169
         Q0170            Q0171           Q0172            Q0173            Q0174            Q0175
         Q0176            Q0177           Q0178            Q0179            Q0180

        *Procedure code requires paper billing.

         National Code            Local Code          Local Code Description
         S0179                    Z1835               Megestrol Acetate tablet, 320 mg
         S0187                    Z1848               Tamoxifin tablet, 10 mg
         S0108                    Z1851               Mercaptopurine tablet, 50 mg
         S0177                    Z1855               Levamisole tablet, 50 mg
         J2820                    Z1871               GM-CSF 250mcg (sargramostim) Vial
         J2820                    Z1884               Prokine 500 mcg
         J0697                    Z1931               Zinacef, 375 mg
         Q0166                    Z2262               Granisetron hydrochloride, oral form


        NOTE: Where both a national code and a local code (“Z code”) are available, the local
              code can be used only for dates of service through October 15, 2003; the national
              code must be used for both electronic and paper claims for dates of service after
              October 15, 2003. Where only a local code is available, it can be used indefinitely,
              but it can be billed only on a paper claim. Where only a national code is
              available, it can be used indefinitely for both electronic and paper claims.

        Injections listed in this section are payable when provided in the nurse practitioner’s office.
        Multiple units may be billed. Take home drugs are not covered. Drugs loaded into an infusion
        pump are not classified as ―take home drugs‖.

    252.443          Other Covered Injections                                                         7-1-07

        Nurse practitioners billing the Arkansas Medicaid Program for injections for treatment or
        immunization purposes should bill the appropriate CPT or HCPCS procedure code for the
        specific injection provided. The immunization procedure codes and descriptions may be found
        in the CPT coding book and in this section of this manual.

        Providers may bill the immunization procedure codes on either the Child Health Services
        (EPSDT) DMS-694 claim form or the CMS-1500 form.

        If the patient is scheduled for immunization only, the provider will not be permitted to bill for an
        office visit, but for the immunization only.

        The following is an alphabetized list of injections with special instructions for coverage and
        billing.


                                                                                                      Section II-47
Nurse Practitioner                                                                               Section II

         Procedure Code   Procedure Description
         J0170            Adrenaline, Epinephrine, Injection, up to 1 ml ampule. (Payable if
                          performed on an emergency basis and is provided in the physician’s
                          office.)
         J2996            Alteplase recombinant, Injection, 10 mg (Payable for eligible
                          Medicaid beneficiaries of all ages.)
         90581*           Anthrax vaccine, for subcutaneous use. Requires paper billing.
         J2910            Aurothioglucose, Injection, up to 50 mg. (Payable for patients with a
                          diagnosis of rheumatoid arthritis.)
         J0702            Betamethasone acetate and Betamethasone sodium phosphate,
                          injection, per 3 mg (Payable for beneficiaries of all ages. However,
                          if the beneficiary is aged 21 or older the injection is covered only for
                          malignant neoplasm, diagnosis code range 140–208.9 or
                          complications related to pregnancy, diagnosis code range 640-
                          648.9)
         J0585*           Botulinum toxin type A, per unit. (Payable for eligible Medicaid
                          beneficiaries of all ages when medically necessary.) Requires
                          paper billing.
         J0636            Calcitriol, Injection, 1 mcg ampule (This code is payable for eligible
                          Medicaid beneficiaries of all ages receiving dialysis due to acute
                          renal failure, diagnosis codes 584-586.)
         J1100            Dexamethasone sodium phosphate, injection, 1 mg (Payable for
                          beneficiaries of all ages. However, if the beneficiary is aged 21 or
                          older the injection is covered only for diagnoses of malignant
                          neoplasm, code range 140–208.9 or for complications relating to
                          pregnancy, code range 640–648.9)
         Q0187            Factor VIIa (coagulation factor, recombinant) for treatment of
                          bleeding episodes in hemophilia A or B patients with inhibitors to
                          Factor VIII or Factor IX. Arkansas Medicaid will approve payment
                          for Factor VIIa only when the primary diagnosis is 286.0, 286.1,
                          286.2 or 286.4.
         J1460            Gamma globulin injections, intramuscular, 1 cc (covered for all ages
                          with no diagnosis restrictions)
         J1470            Gamma globulin injections, intramuscular, 2 cc (covered for all ages
                          with no diagnosis restrictions)
         J1480            Gamma globulin injections, intramuscular, 3 cc (covered for all ages
                          with no diagnosis restrictions)
         J1490            Gamma globulin injections, intramuscular, 4 cc (covered for all ages
                          with no diagnosis restrictions)
         J1500            Gamma globulin injections, intramuscular, 5 cc (covered for all ages
                          with no diagnosis restrictions)
         J1510            Gamma globulin injections, intramuscular, 6 cc (covered for all ages
                          with no diagnosis restrictions)
         J1520            Gamma globulin injections, intramuscular, 7 cc (covered for all ages
                          with no diagnosis restrictions)
         J1530            Gamma globulin injections, intramuscular, 8 cc (covered for all ages
                          with no diagnosis restrictions)

                                                                                             Section II-48
Nurse Practitioner                                                                               Section II

         Procedure Code   Procedure Description
         J1540            Gamma globulin injections, intramuscular, 9 cc (covered for all ages
                          with no diagnosis restrictions)
         J1550            Gamma globulin injections, intramuscular, 10 cc (covered for all
                          ages with no diagnosis restrictions)
         J1560            Gamma globulin injections, intramuscular, over 10 cc (covered for
                          all ages with no diagnosis restrictions)
         J1563            Immune globulin, intravenous 1g (covered for all ages with no
                          diagnosis restrictions)
         J1564            Immune globulin, intravenous 10 mg (covered for all ages with no
                          diagnosis restrictions)
         J7199*           Hemophilia clotting factor, not otherwise classified (Payable for
                          Medicaid beneficiaries of all ages effective for dates of service on
                          and after June 1, 2002.)
         90748            Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for
                          intramuscular use. (Payable for eligible Medicaid beneficiaries
                          under age 21.)
         90660*           Influenza virus vaccine, live, for intranasal use
         90659            Influenza virus vaccine, whole virus, for intramuscular or jet injection
                          use. (Payable for eligible Medicaid beneficiaries age 12 and older.)
         J1750            Iron dextran, injection, 50 mg (Payable for eligible Medicaid
                          beneficiaries of all ages receiving dialysis due to acute renal failure.)
         90735            Japanese encephalitis virus vaccine, for subcutaneous use (payable
                          for under age 21.)
         J9219            Leuprolide acetate implant, 65 mg (Effective for dates of service on
                          or after July 1, 2003. This procedure code is covered for males of
                          all ages with ICD-9-CM diagnosis codes 185, 198.82 or V10.46.
                          Benefit limit is one procedure every 12 months.
         J2260            Milrinone Lactate (Primacor), per 5 ml (payable for eligible Medicaid
                          beneficiaries of all ages with congestive heart failure (diagnosis
                          codes 428-428.9) with places of service ―2‖, ―X‖, ―3‖ or ―4.‖
         90732            Pneumococcal polysaccharide vaccine 23-valent, adult dosage, for
                          subcutaneous or intramuscular use. (This code is payable for
                          eligible Medicaid beneficiaries age 12 and over. Patients age 21
                          and older who receive the injection should be considered by the
                          provider as high risk. All beneficiaries over age 65 may be
                          considered high risk.)
         J2790            Rho D immune globulin, injection, human, one dose package 300
                          mcg, (RhoGAM). (Limited to one injection per pregnancy.)
         J2916            Sodium ferric gluconate complex in sucrose injection, 62.5 mg
                          (Covered for Medicaid eligible beneficiaries of all ages who are
                          allergic to iron dextran. However, if the patient is aged 21 and over
                          there must be a diagnosis of malignant neoplasm (diagnosis code
                          range 140.0-208.91, HIV disease (diagnosis code 042), or acute
                          renal failure (diagnosis code range 584-586)
         90703            Tetanus toxoid, absorbed, for intramuscular or jet injection use.
                          (Payable for eligible Medicaid beneficiaries of all ages.)

                                                                                              Section II-49
Nurse Practitioner                                                                                     Section II

         Procedure Code           Procedure Description
         J3420                    Vitamin B-12 cyanocobalamin, Injection, up to 1000 mcg. (Payable
                                  for patients with a diagnosis of pernicious anemia. Code includes
                                  the B-12, administration and supplies and may not be billed by
                                  units.)

        * Procedure code requires paper billing.

                             Required
         National Code       Modifier       Local Code      Local Code Description
         90371               —              Z1757           Hepatitis B Immune Serum Globulin
                                                            (ISG) (One unit equals 1/2 cc with a
                                                            maximum of 10 units billable per day.)
                                                            (Payable for eligible Medicaid
                                                            beneficiaries of all ages in the
                                                            physician’s office, nurse practitioner’s
                                                            office, outpatient hospital or dialysis
                                                            facility.)
         90385               —              Z2501           Rho (D) immune globulin, injection,
                                                            human, one pre-filled single dose
         J2788
                                                            syringe, 50 mcg, MICRhoGAM. (Limited
                                                            to one per pregnancy.)
         90707               U1             Z2633           Maternal Measles/Mumps/Rubella
                                                            (MMR) (Payable when provided to
                                                            women of childbearing age, ages 21
                                                            through 44, who may be at risk of
                                                            exposure to these illnesses. Coverage is
                                                            limited to two (2) injections per lifetime.)
         90669               —              Z2691           Prevnar™ vaccine (pneumoccal 7-
                                                            valent), pediatric (This vaccine should be
                                                            given in four doses at 2, 4, 6 and 12 to
                                                            15 months of age. Older children ages
                                                            24 to 59 months may receive the vaccine
                                                            if they have special health conditions.
                                                            Reimbursement is for administration
                                                            only.)

        NOTE: Where both a national code and a local code (“Z code”) are available, the local
              code can be used only for dates of service through October 15, 2003; the national
              code must be used for both electronic and paper claims for dates of service after
              October 15, 2003. Where only a local code is available, it can be used indefinitely,
              but it can be billed only on a paper claim. Where only a national code is
              available, it can be used indefinitely for both electronic and paper claims.


    252.444          Billing Procedures for Rabies Immune Globulin and Rabies Vaccine          10-13-03

        The following CPT procedure codes are covered for all ages without diagnosis restrictions.

        90375            90376           90675           90676




                                                                                                  Section II-50
Nurse Practitioner                                                                                     Section II

        These procedure codes require billing on a paper claim with the dosage entered in the units
        column of the claim form for each date of service. The manufacturer’s invoice must be attached
        to each claim. Reimbursement for each of these procedure codes includes an administrations
        fee. Medical policy and billing procedures have not changed for these procedure codes.

    252.445          Epoetin Alpha Injections for Non-ESRD Use                                    10-13-03

        Effective June 1, 2002, procedure code Q0136 – Epoetin alpha (for non-ESRD use) – is covered
        by Medicaid when provided only to patients with anemia associated with rheumatoid arthritis,
        sideroblastic anemia, anemia associated with multiple myeloma, anemia associated with B-cell
        malignancies, myelodysplastic anemia and chemotherapy induced anemia.

        Procedure code Q0136 is payable to the nurse practitioner only when provided in the nurse
        practitioner’s office.

    252.446          Administration of Epoetin Alpha Injections for Chronic or Acute              10-13-03
                     Renal Failure

        Epoetin Alpha injections are covered for Medicaid eligible recipients of all ages with a diagnosis
        of acute or chronic renal failure. The recipient does not have to be receiving dialysis at the time.
        The injections are payable to the nurse practitioner only when provided in the office. Effective
        for dates of service on or after June 1, 2002, the following HCPCS procedure codes are to be
        used when administered for diagnosed acute or chronic renal failure:

         Q9920            Q9921           Q9922           Q9923           Q9924            Q9925
         Q9926            Q9927           Q9928           Q9930           Q9931            Q9932
         Q9933            Q9934           Q9935           Q9936           Q9937            Q9938
         Q9939            Q9940


    252.447          Immunizations For Recipients Under Age 21                                    10-13-03

        The following policy applies when administering antigens to recipients under age 21.

        When providers request Medicaid payment for delivery of the following antigens, the component
        mixture procedure code must be utilized rather than billing for each single antigen separately.
        This policy applies when the antigens are provided on the same date of service.

         Procedure Code        Single Antigen                                 Component Mixture
         90701                 Diptheria, Tetanus Toxoids, Pertusis
                               (DTP)
         90720                                                                DTP/HIB (ages 19-20)
         90704                 Mumps
         90705                 Measles
         90706                 Rubella
         90707                                                                MMR (Measles, Mumps,
                                                                              Rubella) (ages 19-20)
         90708                                                                Measles, Rubella (ages
                                                                              0 through 20)


                                                                                                    Section II-51
Nurse Practitioner                                                                                     Section II

         Procedure Code         Single Antigen                                Component Mixture
         90709                                                                Rubella, Mumps ages 0
                                                                              through 20)


        If the single antigen procedure codes are billed individually for the same dates of service, the
        individual antigen procedure codes will be denied and the provider will be instructed to refile
        using the appropriate component mixture code.

    252.448           Vaccines for Children Program                                                7-1-07

        The Vaccines for Children (VFC) Program was established to generate awareness and access
        for childhood immunizations. Arkansas Medicaid established new procedure codes for billing
        the administration of VFC immunizations for children under the age of 19. To enroll in the VFC
        Program, call the Arkansas Department of Health. Providers may also obtain the vaccines to
        administer from the Arkansas Department of Health. View or print Arkansas Department of
        Health contact information.

        Medicaid policy regarding immunizations for adults (aged 21 and older) remains unchanged by
        the VFC Program.

        Prevnar ™ vaccine (pneumococcal 7-valent, pediatric), procedure code 90669 (Z2691), is now
        available through the VFC program. This vaccine should be given in four doses at 2, 4, 6 and
        12 to 15 months of age. Older children ages 24 to 59 months may receive the vaccine if they
        have special health conditions. Reimbursement is limited to administration fees only.

        NOTE: Where both a national code and a local code (“Z code”) are available, the local
              code can be used only for dates of service through October 15, 2003; the national
              code must be used for both electronic and paper claims for dates of service after
              October 15, 2003. Where only a local code is available, it can be used indefinitely,
              but it can be billed only on a paper claim. Where only a national code is
              available, it can be used indefinitely for both electronic and paper claims.

        Use procedure code 90782 with the appropriate modifier from the list below to receive
        reimbursement for the administration of the following vaccines. The following list includes
        vaccines for children under age 19.

         VACCINE                                          PROCEDURE CODE AND MODIFIER
         Diphtheria:
                 DT                                       90782-E2
                 Td                                       90782-E5
                 DTaP                                     90782-E0
                 DTP-Hib                                  90782-E6
         Hemophilus Influenza Type b:
                 Hib                                      90782-E8
                 DTP/Hib                                  90782-E6
                 PRP-D (for booster use only)             90782-F1
                 PRP-OMP (3 dose schedule)                90782-F2
         Hepatitis B:
                 Hepatitis B                              90782-ED

                                                                                                    Section II-52
Nurse Practitioner                                                                                        Section II

         VACCINE                                            PROCEDURE CODE AND MODIFIER
         Measles/Mumps/Rubella:
                   MMR                                      90782-E3
         Pertussis:
                   DTaP                                     90782-E0
         Poliomyelitis:
                   OPV                                      90782-E4
                   IPV                                      90782-EA
         Chickenpox:
                   Varicella                                90782-EC


    252.449          Influenza Virus Vaccine                                                           7-1-07

        A.    Procedure code 90655, influenza virus vaccine, split virus, preservative free, for children 6
              to 35 months, is currently covered through the VFC program. Claims for Medicaid
              beneficiaries must be filed using modifiers EP and TJ.

              For ARKids First-B beneficiaries, use modifier TJ.

        B.    Effective for dates of service on and after October 1, 2005, Medicaid will cover procedure
              code 90656, influenza virus vaccine, split virus, preservative free, for ages 3 years and
              older.
              1.     For individuals under 19 years of age, claims must be filed using modifiers EP and
                     TJ.
              2.     For ARKids First-B beneficiaries, use modifier TJ.
              3.     For individuals ages 19 and older, no modifier is necessary.
        C.    Effective for dates of service on and after October 1, 2005, procedure code 90660,
              influenza virus vaccine, live, for intranasal use, is covered. Coverage is limited to healthy
              individuals ages 5 through 49 who are not pregnant.
              1.     When filing claims for children 5 through18 years of age, use modifiers EP and TJ.
              2.     For ARKids First-B beneficiaries, the procedure code must be billed using modifier
                     TJ.
              3.     No modifier is required for filing claims for beneficiaries ages 19 through 49.
        D.    Procedure code 90657, influenza virus vaccine, split virus, for children ages 6 through
              35 months, is covered. Modifiers EP and TJ are required.

              For ARKids First-B beneficiaries, use modifier TJ.

        E.    Procedure code 90658, influenza virus vaccine, split virus, for use in individuals ages
              3 years and older, will continue to be covered.
              1.     When filing paper claims for individuals under age 19, use modifiers EP and TJ.
              2.     For ARKids First-B beneficiaries, use modifier TJ.
              3.     No modifier is required for filing claims for beneficiaries aged 19 and older.



                                                                                                       Section II-53
Nurse Practitioner                                                                                     Section II


    252.450          Obstetrical Care and Risk Management Services for Pregnancy                   12-5-05

        Covered nurse practitioner obstetrical services are limited to antepartum and postpartum care
        only. Claims for antepartum and postpartum services are filed using the appropriate office visit
        CPT procedure code.

        A nurse practitioner may provide risk management services listed below if he or she receives a
        referral from the patient’s physician or certified nurse-midwife and if the nurse practitioner
        employs the professional staff required. Complete service descriptions and coverage
        information may be found in Section 214.620 of this manual. The services in the list below are
        considered to be one service and are limited to 32 cumulative units.

         National
         Code          Required Modifiers                   Description
         99402         SA, U1, UA                           Risk Assessment
         99402         SA, U4, UA                           Case Management Services, low-risk case
         99402         SA, U5, UA                           Case Management Services, high-risk case
         99402         SA, UA                               Perinatal Education
         99402         SA, U3, UA                           Social Work Consultation
         99402         SA, U2, UA                           Nutrition Consultation – Individual


        For an early discharge home visit, use one of the applicable CPT procedure codes: 99341,
        99343, 99347, 99348 and 99349.

    252.451          Fetal Non-Stress Test                                                        10-13-03

        The Fetal Non-Stress Test (procedure code 59025) is limited to 2 per pregnancy. If it is
        necessary to exceed this limit, the nurse practitioner must request an extension of benefits and
        submit documentation that establishes medical necessity.


    252.452          Newborn Care                                                                  4-23-10

        All newborn services must be billed under the newborn’s own Medicaid identification number.

        The parent(s) of the newborn will be responsible for applying for and meeting eligibility
        requirements for a newborn to be certified eligible. If the newborn is not certified as Medicaid
        eligible, the parent(s) will be responsible for the charges incurred by the newborn.
        For routine newborn care following a vaginal delivery or C-section, procedure codes 99460,
        99461 or 99463 must be used one time to cover all newborn care visits by the attending
        physician, certified nurse-midwife or, if applicable, a nurse practitioner.
        The newborn care procedure codes 99460, 99461 and 99463 represent the initial Child Health
        Services (EPSDT) newborn care/screen. This screening includes the physical exam of the baby
        and the conference(s) with the newborn’s parent(s). Payment of these codes is considered a
        global rate, and subsequent visits may not be billed in addition to these codes.

        Procedure codes 99460, 99461 and 99463 may be billed on the EPSDT screening paper form
        DMS-694 or on the electronic claim transaction format. These codes may also be filed on the
        CMS-1500; paper or electronically. For information on the Child Health Service (EPSDT)
        Program, call the HP Enterprise Services Provider Assistance Center. View or print HP
        Enterprise Services Provider Assistance Center contact information.

                                                                                                    Section II-54
Nurse Practitioner                                                                                  Section II

        For illness care (e.g., neonatal jaundice), use procedure codes 99221 through 99233. Do not
        use procedure codes 99460, 99461 and 99463 in addition to these codes.
        Note the descriptions, modifiers and required diagnosis range. The newborn care procedure
        codes require a modifier and a primary detail diagnosis of V30.00-V37.21 for all providers. Refer
        to the appropriate manual(s) for additional information about newborn screenings.

        ARKids A (EPSDT) requires an EPSDT claim form or CMS-1500 claim form and may be billed
        electronically or on paper.

         Procedure
         Code           Modifier    Description
         99460          UA          Initial hospital/birthing center care, normal newborn
                                    (global)
         99461          UA          Initial care normal newborn other than hospital/birthing
                                    center (global)
         99463          UA          Initial hospital/birthing center care, normal newborn
                                    admitted/discharged same date of service (global)


        ARKids First B requires a CMS-1500 claim form and may be billed electronically or on paper.

         Procedure
         Code           Modifier    Description
         99460          UA          Initial hospital/birthing center care, normal newborn
                                    (global)
         99461          UA          Initial care normal newborn other than hospital/birthing
                                    center (global)
         99463          UA          Initial hospital/birthing center care, normal newborn
                                    admitted/discharged same date of service (global)




    252.460          Outpatient Hospital Services

    252.461          Emergency Services                                                        10-13-03

        The appropriate CPT procedure codes should be used when billing for nurse practitioner visits in
        an outpatient hospital setting for emergency services.

    252.462          Non-Emergency Services                                                    10-13-03

        Procedure code T1015 (Z0636) should be billed for a non-emergency nurse practitioner visit.

        NOTE: Where both a national code and a local code (“Z code”) are available, the local
              code can be used only for dates of service through October 15, 2003; the national
              code must be used for both electronic and paper claims for dates of service after
              October 15, 2003. Where only a local code is available, it can be used indefinitely,
              but it can be billed only on a paper claim. Where only a national code is
              available, it can be used indefinitely for both electronic and paper claims.



                                                                                                 Section II-55
Nurse Practitioner                                                                                                     Section II


    252.463          Outpatient Hospital Surgical Procedures                                                  10-13-03

        CPT surgical codes for covered nurse practitioner procedures should be used for billing. When
        billing a miscellaneous surgical code, an operative report must accompany the claim form.
        Please refer to Section 252.110 of this manual for CPT codes payable to nurse practitioners.

    252.464          Multiple Surgery                                                                          10-13-03

        If multiple surgical procedures are done on the same date of service, but not in the same
        operative session, each should be coded in the ―Procedures, Services or Supplies‖ field as a
        separate procedure.

    252.465          Observation Status                                                                       10-13-03

        When claims are filed for services provided to a patient in ―observation status,‖ nurse
        practitioners must adhere to Arkansas Medicaid definitions of inpatient and outpatient.
        Observation status is an outpatient designation. Nurse practitioners must also follow the
        guidelines and definitions in Current Procedural Terminology (CPT), under ―Hospital
        Observation Services‖ and ―Evaluation and Management Services Guidelines.‖

        Arkansas Medicaid criteria determining inpatient and outpatient status:
        A.    If a patient is expected to remain in the hospital for less than 24 consecutive hours, and
              this expectation is realized, the hospital and the nurse practitioner should consider the
              patient an outpatient (i.e., the patient is an outpatient unless the nurse practitioner has
              admitted him or her as an inpatient).

        B.    If the nurse practitioner or hospital expects the patient to remain in the hospital for 24
              hours or more, Medicaid deems the patient admitted at the time the patient’s medical
              record indicates the existence of such an expectation, though the nurse practitioner has
              not yet formally admitted the patient.

        C.    Medicaid also deems a patient admitted to inpatient status at the time they have remained
              in the hospital for 24 consecutive hours, even if the nurse practitioner or hospital had no
              prior expectation of a stay of that or greater duration.

    252.466          Billing Examples                                                                         10-13-03

        The following table gives examples of appropriate nurse practitioner claims for several common
        hospital scenarios. In the table, instructions under the headings ―NURSE PRACTITIONER MAY
        BILL…‖ do not necessarily include all services that the nurse practitioner may bill. For instance,
        the provider may bill for interpretation of X-rays or diagnostic tests, though the table below does
        not indicate this. The purpose of this table is to illustrate Arkansas Medicaid observation status
        policy and to give guidance for filing claims related to evaluation and management services.

         ARKANSAS MEDICAID OBSERVATION STATUS POLICY ILLUSTRATION
                                                         NURSE                          NURSE
                                                         PRACTITIONER                   PRACTITIONER MAY
         PATIENT IS                                      MAY BILL FOR                   BILL FOR
         ADMITTED TO                                     TUESDAY                        WEDNESDAY
         OBSERVATION             PATIENT IS              SERVICES:                      SERVICES:
         Tuesday, 3:00 PM        Still in Observation    Appropriate level of Initial   Appropriate level of Initial
                                 Wednesday, 3:00 PM      Observation Care               Hospital Care
         Tuesday, 3:00 PM        Discharged Wednesday,   Appropriate level of Initial   Observation care Discharge
                                 12:00 PM (noon)         Observation Care               Day Management


                                                                                                                  Section II-56
Nurse Practitioner                                                                                                          Section II

         ARKANSAS MEDICAID OBSERVATION STATUS POLICY ILLUSTRATION
                                                              NURSE                          NURSE
                                                              PRACTITIONER                   PRACTITIONER MAY
         PATIENT IS                                           MAY BILL FOR                   BILL FOR
         ADMITTED TO                                          TUESDAY                        WEDNESDAY
         OBSERVATION               PATIENT IS                 SERVICES:                      SERVICES:
         Tuesday, 3:00 PM          Discharged Wednesday,      Appropriate level of Initial   Appropriate level of Initial
                                   4:00 PM                    Observation Care               Hospital Care
         Tuesday, 3:00 PM, after   Discharged Wednesday,      Outpatient surgery             No evaluation and
         outpatient surgery        10:00 AM                                                  Management Services
         Tuesday, 3:00 PM, after   Discharged Tuesday, 7:00   Appropriate level of Initial   Not Applicable;
         exam in Emergency         PM                         Observation Care               Patient was Discharged
         Department–emergency or                                                             Tuesday
         non-emergency



    252.470           Prior Authorization Control Number                                                               3-1-05

        When billing for procedures that have been prior authorized, the 10-digit prior authorization
        control number must be entered in the CMS-1500 claim format. See Section 220.000 of this
        manual for additional information on prior authorization.

    252.480           Medicare                                                                                       11-1-09

        When a beneficiary is dually eligible for Medicare and Medicaid and is provided services that are
        covered by both Medicare and Medicaid, Medicaid will not reimburse for those services if
        Medicare has not been billed prior to Medicaid billing. The beneficiary cannot be billed for the
        charges. See Section 142.700 for detailed information regarding Medicare participation and
        Sections 332.000 through 332.300 for detailed information regarding Medicare-Medicaid
        Crossover claims procedures.

    252.481           Services Prior to Medicare Entitlement                                                           3-1-05

        Services that have been denied by Medicare with the explanation ―Services Prior to Medicare
        Entitlement‖ may be filed with Medicaid. These services should be filed on the CMS-1500 claim
        form for processing and forwarded to the HP Enterprise Services Inquiry Unit. View or print the
        HP Enterprise Services Inquiry Unit contact information.

        These services usually can be filed electronically unless they are covered by Medicare and the
        beneficiary was 65 or older on the date of service. It may be necessary to attach a copy of the
        Medicare denial to the claim.

        A note of explanation should accompany these claims in order that they may receive special
        handling.

    252.482           Services Not Medicare Approved                                                                   3-1-05

        Services that are not Medicare approved for patients with joint Medicare/Medicaid coverage
        usually are not payable by Medicaid unless they are services that are not covered by Medicare,
        but are covered by Medicaid. There are exceptions and those may require special handling.




                                                                                                                       Section II-57

								
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