Arkansas Medicaid Provider Electronic Solutions (PES) Handbook. A user guide for HP Provider Electronic Solutions Software. v. 2.

Transcription

1 Arkansas Medicaid Provider Electronic Solutions (PES) Handbook A user guide for HP Provider Electronic Solutions Software v April 19, 2012 (Revised)

2 HP Arkansas Title XIX Account 500 President Clinton Avenue, Suite 400 Little Rock, Arkansas (501) Hewlett-Packard and the HP logo are registered in the U.S. Patent and Trademark office. HP is an equal opportunity employer and values the diversity of its people. Copyright 2011 Hewlett-Packard. All rights reserved.

3 Contents Contents... i What is PES?... 7 How is this handbook organized?... 7 Getting started... 8 System requirements... 9 How to download PES... 9 How to load PES on a single computer From the Web How to load PES on a network Opening PES Logging on for the first time Setting up options Basic skills Using the keyboard Using the mouse Using the PES window Using menu commands Using command buttons Correcting errors Closing PES Forms Eligibility Request Header Claim Status Request Header Header i

4 278 Prior Authorization Request Header Header Service Service Service Dental Header Header TPL Services Institutional Inpatient Header Header Header Header Header TPL Crossover Service Institutional Nursing Home Header Header Header TPL Crossover Service Copying old claims to submit as new claims ii

5 837 Institutional Outpatient Header Header Header TPL Crossover Service RX Professional Medicaid Header Header Header TPL Crossover Service Service NET RX Professional BreastCare Header Header TPL Service Service NCPDP Pharmacy Header RX Partial RX iii

6 TPL Compound Clinical DUR/PPS & Coupon NCPDP Pharmacy Reversal Header Service Long Term Care Census Census Transaction responses Eligibility Response(s) Claim Status Response(s) Prior Authorization Response(s) Electronic Remittance Advice Acknowledgement(s) Rejected Response Report NCPDP Pharmacy Response(s) TA1 Interchange Acknowledgement(s) Long Term Care Census Response(s) Supplemental Eligibility Response Report(s) Communication Submission Sending transactions Receiving files Web Submission Password Change/Reminder Resubmission View Batch Response and 999s View Batch LTC Census Response iv

7 View Rejected Response Report View Supplemental Eligibility Response View Batch 835 ERA Response View Communication Log Lists Building a list in advance Building a list as you enter data Preloaded lists Lists to build Billing/Requesting Provider Beneficiary/Patient/Cardholder/Client Attending/Operating Provider Facility/Performing/Referring/Service Provider NCPDP Billing/Prescribing/NET Destination Provider Facility Name and Address Admit Source Attachment Type Code Carrier Condition Code Diagnosis Modifier Occurrence Patient Status Place of Service Policy Holder Procedure/NDC Revenue Type of Bill v

8 Value Code Reports Detail Forms reports Summary Forms reports List reports Tools Archive Creating an archive Restoring an archive base Recovery Compact Repair Unlock Change Password Options Batch Web Retention Security Security Maintenance Troubleshooting vi

9 What is PES? HP s Medicaid software, Provider Electronic Solutions (PES), enables health care providers and retail pharmacies to verify beneficiary eligibility, request prior authorizations, and submit claims electronically. PES version 2.15 meets the requirements of the Health Insurance Portability and Accountability Act (HIPAA) for the transmission of electronic transactions. How is this handbook organized? The Arkansas Medicaid PES Handbook helps new and experienced users load, set up, and use PES software. It includes the following sections: Section Getting Started Forms Communication Lists Reports Tools Security Troubleshooting Content How to load and set up the software, log on, establish a password, and access the program. How to create eligibility-verification requests, prior authorization requests, and claims. Also includes information about transaction responses. How to submit transactions, view submission reports, and view communication log files. How to build the lists you use regularly. How to view and print detail or summary reports. How to archive forms; compact, repair, or unlock the database; upgrade; change your password; and set up software options. How to set up and change your password. How to solve the most common problems. 01/19/12 7

10 Getting started You can submit electronic transactions to Arkansas Medicaid only in HIPAA-compliant format. That means you must have: Vendor software that meets the requirements of the Health Insurance Portability and Accountability Act (HIPAA) for the transmission of electronic transactions. OR HP Provider Electronic Solutions software, v (available from the Arkansas Medicaid website at OR Access to the on-line claim-submission application on the Arkansas Medicaid website ( AND A submitter registration ID which is available through the Arkansas Medicaid website at or through the EDI Support Desk at (800) in state or (501) local or out-of-state. If you have PES software older than version 2.0, it does not meet the requirements of the Health Insurance Portability and Accountability Act (HIPAA) for the transmission of electronic transactions and cannot be upgraded. HIPAA-related changes to processing are so extensive that you must replace this older software (and, consequently, rebuild your database) with the full application of the current version. If you are using PES 2.09 or greater, you can upgrade to 2.15 by applying the upgrades available on the Arkansas Medicaid website ( NOTE: Always use the upgrade function to keep PES software current. Do not load a new, full version of the software or your claim data and lists will be deleted. If you want to upgrade any version of PES prior to version 2.09, contact the EDI Support Center at (800) for assistance. Versions of PES 2.09 or greater do not require that you apply sequential upgrades, but you may upgrade to PES 2.15 to have the latest version of the software. Before you upgrade to PES 2.15, create a copy of the ARHIPAA folder and rename it. This serves as a backup in the event files are lost or damaged during the upgrade process. PES can be set up on a computer s hard disk or on a network. You can choose between Typical and Workstation (network) setup. You can set up PES on as many computers as needed. NOTE: PES cannot be used with terminal server solutions. 04/19/12 8

11 System requirements PES requires the following hardware and software, at minimum: Windows 2000/XP/Windows 7 Pentium II 64 megabytes RAM 100 megabytes free hard-disk space 800 x 600 resolution MS Internet Explorer 6.0 or greater NOTE: HP no longer supports PES installation on Windows 98. How to download PES To download HP Provider Electronic Solutions software, version 2.15, follow the instructions on the Arkansas Medicaid website at The file is large, so if you have a slow connection to the Internet the download may take a long time. If the download doesn't work for you, call the EDI Support Center at (800) /19/12 9

12 How to load PES on a single computer From the Web 1. Double-click the downloaded file. The Welcome screen opens. 2. Click Next. The Setup Type screen opens. 01/19/12 10

13 3. Click Typical. Click Next. The Choose Destination Location screen opens. 4. Click Next to accept the default destination for the software, C:\ARHIPAA. The Choose base Destination Location screen opens. 5. Click Next to accept the default destination for the database, C:\ARHIPAA. A graphic shows the progress of the procedure. You can cancel at any time by clicking the Cancel button. 6. When loading is complete, click Finish. 01/19/12 11

14 How to load PES on a network 1. Load PES on the server or primary computer, choosing Typical and accepting all defaults. 2. Load PES on each workstation, choosing Workstation and browsing to the location where the database resides. Only the PES application is loaded on the workstation. The database has already been loaded on the network server or primary computer and is shared by all workstations. NOTE: If you need assistance installing PES on your network or resolving transmission problems when using PES on your network, you will need to contact the technical support representative or team in your office. EDI does not support network issues. Opening PES After you load PES, you can open it in either of these ways: Double-click the AR HP Provider Electronic Solutions icon on your desktop. Select Start; select Programs; and click AR HP Provider Electronic Solutions. Logging on for the first time 1. Open PES. The Logon box opens with User ID filled in: pes-admin. Type HP-pes in the Password field, and then select OK. 01/19/12 12

15 2. A Password Expired notice opens. If you choose Cancel, the LogOn ends and PES closes. If you choose OK, a new box opens allowing you to create a unique password. 3. In the Old Password field, type HP-pes. In the New Password and Rekey New Password fields, type the password you want to use. Password Requirements Passwords are not case-sensitive. A password can be any combination of alpha, numeric, and special characters. A password must be 5-10 characters in length. 4. From the list in the Question field, select a security question. In Answer and Rekey Answer, type the answer to the question. 5. Select OK. The system notifies you that your password has been updated. 6. Select OK. The system prompts you to set up your personal options. To change your password any time after your first log on, see Security Maintenance. 01/19/12 13

16 Setting up options The first time you use PES you must set up the following options: Batch, Web, and Retention. For instructions on how to set up these options, see the Options section of this manual. In PES, Options can be found under the Tools menu. Basic skills In PES, the keyboard, menus, toolbars, and command buttons are similar to those of other MS Windows software. If you are a first-time computer user or have limited experience, take the time to familiarize yourself with the PES screens and how they work. Using the keyboard Some computer users must or prefer to use the keyboard to move around on a screen. The keystrokes listed in the following table enable you to navigate PES without a mouse device. Key Tab or Enter Shift + Tab Left arrow Right arrow Up arrow Down arrow F1 ESC ALT + down arrow ALT + (shortcut key) Action Go to the next field. Go to the previous field. Move backward within a field. Move forward within a field. Scroll up through a list. Scroll down through a list. Open online help when the cursor is in a data-entry field. Exit the help window. Show available list choices. Each shortcut key is identified on menus by an underlined letter. Press ALT plus this character to activate the command. Shortcut keys vary from screen to screen. Using the mouse You can use a mouse device to position the cursor on the screen, select an item from a list, or activate a command. Click: Slide the mouse to move the cursor into position, and then click the left mouse button. 01/19/12 14

17 Double-click: To add data to a list, double-click the left mouse button in the field to open a data-entry window. Right-click: Use the right mouse button to Cut, Copy, Paste, and Select All. Using the PES window Menu bar The menu bar at the top of the main PES window lists all application functions: File, Forms, Communication, Lists, Reports, Tools, Security, Window, and Help. When you select a command, the screen associated with that command opens inside the main PES window. This screen also has a menu bar. 01/19/12 15

18 Toolbar Toolbars provide shortcuts for frequently used menu commands. A toolbar consists of icons that represent menu commands. Select the icon to activate the command. To see a name or brief description of the icon, hold the cursor over the icon without clicking. The description displays below the cursor. Just below the main menu bar is a toolbar with an icon for each type of PES transaction. These icons are defined in the table below. 270 Eligibility Request 276 Claim Status Request 278 Prior Authorization Request 837 Dental 837 Institutional Inpatient 837 Institutional Inpatient Nursing Home 837 Institutional Outpatient 837 Professional Medicaid 837 Professional BreastCare NCPDP Pharmacy NCPDP Pharmacy Reversal Long Term Care Census Tabs Related data-entry fields are organized into tabs. To reveal a tab, select the tab name. List indicator and list If a button with a down arrow is attached to a field, that means the field contains a list. To display the list, select the arrow. If the list has scroll bars, use them to view the entire list. If you double-click in a list field, a data-entry window opens to allow you to add to the list. Details Detail rows list line items within a claim or entries in a list. Status bar The status bar shows the current state of PES, such as Ready or New Record Added. Active window You can open up to three forms, lists, or reports in any combination. On the Window menu, select the way in which you want to view screens that are displayed simultaneously: cascaded, tiled, or layered. Command buttons Command buttons displayed on each screen vary according to the transaction. 01/19/12 16

19 Using menu commands Command File Edit View Forms Communication Lists Reports Tools Security Window Help Action On the main menu, exit PES. On other menus, add, delete, and print. Cut, copy, or paste data. Add, copy, or delete a service. Filter, find, or sort records. View responses and error reports. Select a form for creating a transaction. Submit batches of forms and receive batch responses, resubmit batches of forms and view communication log files. Add and edit data in reference lists. Print summary or detail reports with information from forms or reference lists. Create and work with archives, maintain the database and change setup options. Store ID and password. Modify how windows are displayed or move between windows. Obtain help about PES functions, screens, menus and fields using Contents and Index. Select About to view information about PES, such as version and copyright. 01/19/12 17

20 Using command buttons Command buttons displayed on each screen vary according to the transaction. Command button Add Copy Delete Undo All Save Find Print Close Action Open a new form that is ready for data entry. Copy the highlighted form and open the copy for editing. Delete the current form. Reverse all changes to the current form. You can undo only the changes made since the last time you saved the form. Save the data you have typed in the current form or list. When you save a form, the data is checked. If required fields are empty or the data contains errors (for example, if a Provider ID does not have the correct number of digits), the errors are listed so you can correct them. When you save a form, its status is updated in the detail line to R (Ready to be transmitted). Open a window to search for data within a list. Display eligibility transactions, claim forms and reports in a report format to be viewed or printed. Also display lists in a form that can be viewed or printed. Close the form window. If you have made changes to the current form, PES prompts you to save those changes. 01/19/12 18

21 Command button Add Srv Copy Srv Delete Srv Action Add a detail line to a transaction; open the data-entry fields for additional input. Copy an existing detail line so it can be modified and added to the transaction. Remove a detail line that was added in error. Correcting errors You cannot save a form that has incorrect or incomplete data. If all of the required data is not included in a form or list, a list of errors opens when you try to save the form. When you double-click each error message, the cursor will move to the erroneous field for correction. NOTE: PES only recognizes errors such as an empty field or alpha characters in a field that should be all numbers. PES cannot catch content errors, such as an incorrect number of units. If you cannot complete the form but you want to save the data you have typed so far, select Incomplete. The transaction is saved with status I and cannot be transmitted until it is complete. Closing PES Use one of the following options to close PES: Click the X at the upper-right corner of the screen. On the File menu, select Exit. On the toolbar, click the Exit icon. If you have not saved your work, PES prompts you to save your changes. Select Yes to save your work and close PES. Select No to close the active window and keep PES open. Select Cancel to keep both the active window and PES open. 01/19/12 19

22 Forms Arkansas Medicaid transactions can be submitted electronically using forms. The Forms menu includes the following commands: 270 Eligibility Request 276 Claim Status Request 278 Prior Authorization Request 837 Dental 837 Institutional Inpatient 837 Institutional Nursing Home 837 Institutional Outpatient 837 Professional Medicaid 837 Professional BreastCare NCPDP Pharmacy NCPDP Pharmacy Reversal Long Term Care Census 01/19/12 20

23 270 Eligibility Request Use the 270 Eligibility Request form to verify beneficiary eligibility in the Arkansas Medicaid Program. Verify eligibility every time services are rendered. Eligibility can be checked only for the current day and up to 365 days into the past. Eligibility cannot be verified for future dates. The 270 Eligibility Request form has one tab: Header. To open the 270 Eligibility Request form On the Forms menu, select 270 Eligibility Request. OR On the toolbar of the main screen, click the 270 Eligibility Request icon. 01/19/12 21

24 Header To complete the 270 Eligibility Request form, enter data into each of the following fields. Provider ID Provider s NPI or Arkansas Medicaid Provider ID. If the provider is eligible for an NPI, the NPI must be used here. If the provider is not eligible for an NPI, the provider s Arkansas Medicaid provider identification number is used. Select the Provider ID from the list. If the ID number is not in the list, double-click in the Provider ID field. A data-entry screen opens. Type the Provider ID. Select Save, and then choose Select. Beneficiary ID Beneficiary s ID. Select from the list. OR Type any of the following sets of data for the beneficiary: Arkansas Medicaid Beneficiary ID Date of birth and full name (first/middle initial/last) Social Security number and date of birth Social Security number and full name (first/middle initial/last) If the beneficiary s information is in your list, the remaining beneficiary 01/19/12 22

25 fields are filled automatically. If you want to add the beneficiary to your list, double-click in the Beneficiary ID field. A data-entry screen opens. Type the Beneficiary ID. Select Save, and then choose Select. Account # DOB SSN Last name First name MI From DOS To DOS Trace # Unique patient ID assigned by your facility. If the beneficiary s information is in your list, this field is filled automatically; however, you can change the data by typing over it. Beneficiary s date of birth. Format: MM/DD/YYYY. Beneficiary s Social Security number. Beneficiary s last name. Beneficiary s first name. Beneficiary s middle initial. Beginning date for which you want to verify eligibility. You can type any date up to 365 days in the past. Format: MM/DD/YYYY. Ending date for which you want to verify eligibility. Format: MM/DD/YYYY. Do not use a future date. Filled automatically by PES. When you have completed the form, Select Save to save the transaction OR Select Add to save the transaction and open a new form for data entry. You can then use the Batch Submission feature to verify eligibility for a number of beneficiaries at the same time. For more information, see Sending transactions. 01/19/12 23

26 276 Claim Status Request Use the 276 Claim Status Request form to check the status of a claim that has already been submitted. The 276 Claim Status Request form has two tabs: Header 1 Header 2 To open the 276 Claim Status Request form On the Forms menu, select 276 Eligibility Request. OR On the toolbar of the main screen, click the 276 Claim Status Request icon. 01/19/12 24

27 Header 1 The 276 Claim Status Request form opens with the Header 1 tab on top. To complete Header 1, enter data into each of the following fields. Provider ID Provider s NPI or Arkansas Medicaid Provider ID. If the provider is eligible for an NPI, the NPI must be used here. If the provider is not eligible for an NPI, the provider s Arkansas Medicaid provider identification number is used. Select the Provider ID from the list. If the ID number is not in the list, double-click in the Provider ID field. A data-entry screen opens. Type the Provider ID. Select Save, and then choose Select. Beneficiary ID Last name First name Beneficiary s ID. If the beneficiary s information is in your list, the remaining beneficiary fields are filled automatically. If you want to add the beneficiary to your list, double-click in the Beneficiary ID field. A data-entry screen opens. Type the Beneficiary ID. Select Save, and then choose Select. Filled automatically based on Beneficiary ID. Filled automatically based on Beneficiary ID. 01/19/12 25

28 Header 2 Select the Header 2 tab and enter data into each of the following fields. From DOS To DOS Charges Medical Record # Claim # Trace # Beginning date of service. Format: MM/DD/YYYY. Ending date of service. Format: MM/DD/YYYY. Total charges for the services rendered. Number assigned by you that identifies the beneficiary in your records. Can contain alpha and numeric characters. Optional. 13-digit ICN of the original claim. Filled automatically by the system. When you have completed the form, Select Save to save the transaction. OR Select Add to save the transaction and open a new form for data entry. 01/19/12 26

29 278 Prior Authorization Request Use the 278 Prior Authorization Request form to obtain approval to perform procedures before services are rendered. The 278 Prior Authorization Request form has five tabs: Header 1 Header 2 Service 1 Service 2 Service 3 To open the 278 Prior Authorization Request form On the Forms menu, select 278 Prior Authorization Request. OR On the toolbar of the main screen, click the 278 Prior Authorization Request icon. 01/19/12 27

30 Header 1 The 278 Prior Authorization Request form opens with the Header 1 tab on top. To complete Header 1, enter data into each of the following fields. Requesting Provider ID NPI or Arkansas Medicaid Provider ID of the provider requesting prior authorization. If the provider is eligible for an NPI, the NPI must be used here. If the provider is not eligible for an NPI, the provider s Arkansas Medicaid provider identification number is used. Select the Provider ID of the provider requesting prior authorization from the list. If the ID number is not in the list, double-click in the Requesting Provider ID field. A data-entry screen opens. Type the Provider ID. Select Save, and then choose Select. PA Reviewing Department Beneficiary ID Department for the type of prior authorization you are requesting. Select the department from the list, Beneficiary s ID. Select the Beneficiary ID from the list. If the beneficiary s information is already a part of your list, the remaining beneficiary fields are filled automatically. If you want to add the beneficiary to your list, double-click in the 01/19/12 28

31 Beneficiary ID field. A data-entry screen opens. Type the Beneficiary ID. Select Save, and then choose Select. Account # Last Name First Name Unique patient ID assigned by your facility. If the beneficiary s information is in your list, this field is filled automatically; however, you can change the data by typing over it. Beneficiary s last name. Beneficiary s first name. Attachment Type Transmission- Code Control # Comment Code for the title or contents of a document, report, or supporting item for this claim, if applicable. Select the code from the list. If the ID code is not in the list, double-click in the Attachment Type field. A data-entry screen opens. Type the Attachment Type. Select Save, and then choose Select. Code that defines the method or format by which reports are to be sent, if applicable. Select the code from the list. Report transmission code you have assigned to the attachment, if applicable. This code can consist of alpha or numeric characters, or both. Freeform message clarifying the prior authorization request. Maximum: 80 characters. 01/19/12 29

32 Header 2 Select the Header 2 tab and enter data into each of the following fields. Diagnosis Codes Primary Admit Other (1 through 6) Primary diagnosis code for the visit. Select the primary diagnosis from the list. If the code is not in the list, double-click in the Primary field. A data-entry screen opens. Type the necessary data. Select Save, and then choose Select. Diagnosis code for the condition that prompted the beneficiary s admission to the facility. Select the code from the list. If the code is not in the list, double-click in the Admit field. A data-entry screen opens. Type the Admit code. Select Save, and then choose Select. An additional diagnosis code related to the visit, if applicable. Select the code from the list. If the code is not in the list, double-click in the field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Related Causes. If the services were made necessary by an accident or employment-related incident, complete the following fields. Related Code for the appropriate related cause. 01/19/12 30

33 Causes (1 through 3) Incident Date State Service Provider ID If you selected a code for 1, 2, or 3, then the date of the incident is required. Format: MM/DD/YYYY. If the incident was an auto accident, select the code for the state in which the accident occurred. NPI or Arkansas Medicaid Provider ID of the provider who will render the services. If the provider is eligible for an NPI, the NPI must be used here. If the provider is not eligible for an NPI, the provider s Arkansas Medicaid provider identification number is used. Select the ID from the list. If the ID number is not in the list, double-click in the Service Provider ID field. A data-entry screen opens. Type the Service Provider ID. Select Save, and then choose Select. Place of Service Trace # 2-digit code for the place at which service was delivered. Select the place of service from the list. If the code is not in the list, double-click in the Place of Service field. A data-entry screen opens. Type the Place of Service. Select Save, and then choose Select. Filled automatically by PES. 01/19/12 31

34 Service 1 Select the Service 1 tab and enter data into each of the following fields. Procedure Qualifier Procedure Units Amount From DOS To DOS Modifiers (1 through 4) Tooth Numbers 1-42 Code for the type of procedure. CPT or HCPCS procedure code. Select the appropriate code from the list. If the procedure code is not in the list, double-click in the Procedure field. A data-entry screen opens. Type the procedure code. Select Save, and then choose Select. Number of days, services, time intervals, or items, depending on the service provided. Dollar amount for the requested services. Beginning date for the service to be provided. Ending date for the service to be provided. Code(s) that further define the procedure code. Select from the list(s). If the code is not in the list, double-click in a modifier field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Numbers of teeth for which services are being requested. See the National Standard Tooth Numbering System of the American Dental Association. 01/19/12 32

35 Service 2 Select the Service 2 tab and enter data into each of the following fields. Oxygen Equipment Types (1 and 2) Flow Rate Delivery Test Condition Code Test Findings Codes (1 through 3) Arterial Blood Gas Daily Use Hourly Use Portable System Flow Type of equipment prescribed for the delivery of oxygen. Oxygen flow rate in liters per minute. Code for the form of delivery prescribed. Code for the conditions under which the beneficiary was tested. Findings of the oxygen test(s) performed on the beneficiary. Value of arterial blood gases for the beneficiary. Number of times per day that the beneficiary must use oxygen. Number of hours per period that the beneficiary must use oxygen. Oxygen flow rate for a portable oxygen system in liters per minute. 01/19/12 33

36 Rate Saturation RT Order Reason Value of oxygen saturation. Special instructions from the respiratory therapist. Freeform description of the reason the equipment is needed. 01/19/12 34

37 Service 3 Select the Service 3 tab and enter data into each of the following fields. Home Health Prognosis Request Type Medicare SNF Facility Type Surgery Type Surgery Procedure Physician s prognosis for the beneficiary. Type of prior authorization request. Code showing whether the beneficiary is also a Medicare beneficiary. Code showing whether the beneficiary is receiving care in a Skilled Nursing Facility. Code for the type of facility from which the beneficiary was discharged. Code for the type of procedure, including HCPCS code, diagnosis code, tooth code, and NDC. Surgical procedure code for the procedure performed. Select the code from the list. If the code is not in the list, double-click in the Surgery Procedure field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Dates Surgery Admission Date on which surgery was performed. Admission date of beneficiary s most recent inpatient stay. 01/19/12 35

38 Discharge Original Last Visit Last Contact Phys Order Cert From Cert To Discharge date of beneficiary s most recent inpatient stay. Date on which covered home health services began. Date on which beneficiary was last seen by the physician. Date of the home health agency s last contact with the physician. Date on which the agency received oral orders from the provider to start care. Requested beginning date for services. Requested ending date for services. When you have completed the form, Select Save to save the transaction. OR Select Add to save the transaction and open a new form for data entry. You can then use the Batch Submission feature to submit a number of forms at the same time. For more information, see Sending transactions. 01/19/12 36

39 837 Dental Use the 837 Dental form to file claims for dental services. The 837 Dental form has four tabs: Header 1 Header 2 TPL (Third Party Liability, added only when applicable) Services To open the 837 Dental form On the Forms menu, select 837 Dental. OR On the toolbar of the main screen, click the 837 Dental icon. 01/19/12 37

40 Header 1 The 837 Dental form opens with the Header 1 tab on top. To complete Header 1, enter data into each of the following fields. Provider ID Claim Frequency NPI or Arkansas Medicaid Provider ID of the provider. Select from the list. If the ID number is not in the list, double-click in the Provider ID field. A data-entry screen opens. Type the Provider ID. Select Save, and then choose Select. Claim Frequency code. Select 1 to submit an original claim. Select 7 to replace a prior claim (indicated by the ICN). Copy the original claim, change the Claim Frequency to 7, type the 13-digit original ICN, correct the claim, and save the transaction. NOTE: To successfully adjust a claim, you cannot alter the provider ID, beneficiary ID, claim type, or number of details. A claim can only be adjusted after it is listed as paid on a remittance advice. It cannot be adjusted during the week that it is originally submitted. Select 8 to void (cancel) a prior claim (indicated by the ICN) and have the payment withheld from future payments. NOTE: You must complete a voided claim exactly as it was originally submitted for the cancellation to be successful. You 01/19/12 38

41 can increase your accuracy when voiding claims by copying the original claim, changing the Claim Frequency to 8, typing the 13- digit ICN, and saving the transaction. Original Claim # Beneficiary ID Account # Last Name First Name 13-digit ICN of the original claim. Use only when Claim Frequency is 7 or 8. Beneficiary s ID. Select the ID from the list. If the beneficiary s information is part of your list, the remaining beneficiary fields are filled automatically. If you want to add the beneficiary to your list, double-click in the Beneficiary ID field. A data-entry screen opens. Type the Beneficiary ID. Select Save, and then choose Select. Unique patient ID assigned by your facility. If the beneficiary s information is part of your list, this field is filled automatically; however, you can change the data by typing over it. Filled automatically, based on Beneficiary ID. Filled automatically, based on Beneficiary ID. Attachment Type Code Transmission- Code Control # Code for the title or contents of a document, report, or supporting item for this claim, if applicable. Code that defines the method or format by which reports are to be sent, if applicable. Report transmission code you have assigned to the attachment, if applicable. This code can consist of alpha or numeric characters, or both. 01/19/12 39

42 Header 2 Select the Header 2 tab and enter data into each of the following fields. Place of Service EPSDT Prior Authorization 2-digit code for the place at which service was delivered. Select Y if the service was rendered as part of the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT). If the service was not part of the EPSDT Program, leave the field blank. 10-digit prior authorization number assigned by the Arkansas Medicaid Dental Care Unit, if applicable. Orthodontic Treatment Total Months Months Remaining Related Causes (1 through 3) Incident Date Accident State Total number of months of orthodontic treatment. Number of treatment months remaining. If the services were made necessary by an accident or employmentrelated incident, select the code for the appropriate related cause(s). If you selected a Related Cause, then the date of the accident is required. Format: MM/DD/YYYY. If the incident was an auto accident, select the code for the state in 01/19/12 40

43 which the accident occurred. TPL Indicator If the beneficiary has primary insurance coverage for dental services, select Y from the list; a TPL tab is added to the form and must be completed. If the beneficiary does not have primary coverage, select N. 01/19/12 41

44 TPL Select the TPL tab (if any) and enter data into each of the following fields. Claim Filing Indicator Code Paid Amount Denial Date Code for the type of other insurance claim being submitted. Total dollar amount paid by the primary insurance. If Paid Amount is 0, type the date on which the claim was denied by primary insurance. Format: MM/DD/YYYY. Policy Holder Carrier Code Carrier Name Member/ Policy # Code identifying the insurance carrier the third party liability (TPL) carrier code assigned by the Arkansas Medicaid Program. Select the code from the list. If the code is not in the list, double-click in the Carrier Code field. A data-entry screen opens. Enter a valid carrier code from the most current list found at Select Save, and then choose Select. Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. 01/19/12 42

45 Last Name First Name Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. 01/19/12 43

46 Services Select the Services tab and enter data into each of the following fields. Date of Service Appliance Placement Date Tooth Surfaces (1 through 5) Oral Cavity Designation (1 through 5) Placement Ind Prior Placement Date Units Date on which services were provided. Format: MM/DD/YYYY. If an appliance was placed, the date on which it was placed. Format: MM/DD/YYYY. Tooth number, if applicable. Affected tooth surface(s), if applicable. Affected area(s) of the oral cavity, if applicable. Code indicating whether this placement is initial or replacement. If you select R, you must complete Prior Placement Date. If Placement Ind is R, the prior placement date. Format: MM/DD/YYYY. Number of days, services, time intervals, or items, depending on the service provided. 01/19/12 44

47 Charges Procedure Performing Provider ID Total charges for the services rendered. 5-digit American Dental Association procedure code. Select the appropriate procedure code from the list. If the procedure code is not in the list, double-click in the Procedure field. A data-entry screen opens. Type the procedure code. Select Save, and then choose Select. NPI of the provider who rendered the service. Select the ID from the list. If the ID number is not in the list, double-click in the Performing Provider ID field. A data-entry screen opens. Type the ID of the provider. Select Save, and then choose Select. NOTE: This field is completed only when the billing provider has a group provider number. If the billing provider number on Header 1 has an entity type of 2 (non-person), then the Performing Provider ID must have an entity type of 1 (person). The provider ID used in Header 1 and performing provider ID used in Services cannot be the same number. If they are the same, leave the performing provider ID field blank. When you have completed the form, Select Save to save the transaction. OR Select Add to save the transaction and open a new form for data entry. 01/19/12 45

48 837 Institutional Inpatient Use the 837 Institutional Inpatient form to file UB-92 inpatient claims. The 837 Institutional Inpatient form has eight tabs: Header 1 Header 2 Header 3 Header 4 Header 5 TPL (Third Party Liability, added only when applicable) Crossover (Medicare Crossover, added only when applicable) Service To open the 837 Institutional Inpatient form On the Forms menu, select 837 Institutional Inpatient. OR On the toolbar of the main screen, click the 837 Institutional Inpatient icon. 01/19/12 46

49 Header 1 The 837 Institutional Inpatient claim form opens with the Header 1 tab on top. To complete Header 1, enter data into each of the following fields. Provider ID Type of Bill NPI or Arkansas Medicaid Provider ID of the provider. Select the Provider ID from the list. If the ID number is not in the list, double-click in the Provider ID field. A data-entry screen opens. Type the Provider ID. Select Save, and then choose Select. 3-digit Type of Bill code. Select from the list. If the code is not in the list, double-click in the Type of Bill field. A data-entry screen opens. Type the Type of Bill. Select Save, and then choose Select. NOTE: Use the type of bill code ending in 8 to void (cancel) a prior claim (indicated by the ICN) and have the payment withheld from future payments. You must complete a voided claim exactly as it was originally submitted for the cancellation to be successful. You can increase your accuracy when voiding claims by copying the original claim, changing the Type of Bill to 8, typing the 13-digit ICN, and saving the transaction. Use 7 as the third digit of the type of bill to replace a prior claim (indicated by the ICN). Copy the original claim, change the third digit 01/19/12 47

50 of the type of bill to 7, type the 13-digit original ICN, correct the claim, and save the transaction. To successfully adjust a claim, you cannot alter the provider ID, beneficiary ID, claim type, or number of details. A claim can only be adjusted after it is listed as paid on a remittance advice. It cannot be adjusted during the week that it is originally submitted. Original Claim # Beneficiary ID Account # Last Name First Name From DOS To DOS Medical Record # Patient Status Prior Authorization If the third digit of the Type of Bill code is 7 or 8, the original 13-digit claim number assigned by Arkansas Medicaid/HP. Beneficiary s ID. Select the beneficiary ID from the list. If the beneficiary s information is already a part of your list, the remaining beneficiary fields are filled automatically. If you want to add the beneficiary to your list, double-click in the Beneficiary ID field. A data-entry screen opens. Type the Beneficiary ID. Select Save, and then choose Select. Unique patient ID assigned by your facility. If the beneficiary s information is already a part of your list, this field is filled automatically; however, you can change the data by typing over it. Filled automatically, based on Beneficiary ID. Filled automatically, based on Beneficiary ID. Beginning date of service. Format: MM/DD/YYYY. Ending date of service. Format: MM/DD/YYYY. Number assigned by you that identifies the beneficiary in your records. Can contain alpha and numeric characters. Optional. 2-digit patient status code. Select from the list. If the code is not in the list, double-click in the Patient Status field. A data-entry screen opens. Type the Patient Status. Select Save, and then choose Select. 10-digit prior authorization number assigned by Arkansas Medicaid, if applicable. Attachment Type Code Transmission Code Control # Code for the title or contents of a document, report, or supporting item for this claim, if applicable. Code that defines the method or format by which reports are to be sent, if applicable. Report transmission code you have assigned to the attachment, if 01/19/12 48

51 applicable. This code can consist of alpha or numeric characters, or both. 01/19/12 49

52 Header 2 Select the Header 2 tab and enter data into each of the following fields. Diagnosis Codes Primary Other (1 through 8) Admit Emergency Primary diagnosis code for the visit. Select from the list. If the code is not in the list, double-click in the Primary field. A data-entry screen opens. Type the diagnosis code. Select Save, and then choose Select. Additional diagnosis code related to the visit, if applicable. Select from the list. If the code is not in the list, double-click in the field. A data-entry screen opens. Type the diagnosis code. Select Save, and then choose Select. Diagnosis code for the condition that prompted the beneficiary s admission to the facility. Select from the list. If the code is not in the list, double-click in the Admit field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Diagnosis code describing an injury, poisoning, or adverse effect for which the service is being billed. Select from the list. If the code is not in the list, double-click in the 01/19/12 50

53 Emergency field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Surgical Codes/Dates (1 through 6) Operating Physician ID Surgical procedure code for the procedure performed during the billing period. Select from the list. If the code is not in the list, double-click in a Code field. A data-entry screen opens. Type the procedure code. Select Save, and then choose Select. Type the date of the procedure in the adjacent field. Format: MM/DD/YYYY. Operating physician s NPI or Arkansas Medicaid Provider ID number. Select from the list. If the NPI is not in the list, double-click in the Operating Physician ID field. A data-entry screen opens. Type the Physician ID. Select Save, and then choose Select. 01/19/12 51

54 Header 3 Select the Header 3 tab and enter data into each of the following fields. Occurrence Codes/Dates (1 through 8) Occurrence code defining a significant event relating to this claim. (See the National Uniform Billing Committee manual.) Select from the list. If the code is not in the list, double-click in a Code field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Type the date of the occurrence in the adjacent field. Format: MM/DD/YYYY. PSRO Dates From To Condition Codes (1 through 7) First day approved by Provider Statistical and Reimbursement Organization (PSRO) for a hospital stay. Format: MM/DD/YYYY. Last day approved by Provider Statistical and Reimbursement Organization (PSRO) for a hospital stay. Format: MM/DD/YYYY. Code for a condition related to this bill that may affect payer processing. (See the National Uniform Billing Committee manual.) Select the code from the list. If the code is not in the list, double-click in a Condition Code field. A data-entry screen opens. Type the necessary data. Select Save, and then choose Select. 01/19/12 52

55 Header 4 Select the Header 4 tab and enter data into each of the following fields. Value Codes/Amounts (1 through 12) Code Value codes and corresponding amounts identify data elements necessary to process this claim as qualified by the payer organization. The value codes can be found in the National Uniform Billing Committee (NUBC) manual. Value codes used for claim processing by Arkansas Medicaid are listed below: Value Code 80 is required with an amount that equals the number of inpatient covered days. Value Code 81 is optional with an amount that equals the number of inpatient non-covered days. If you enter 81, the amount for non-covered days must be greater than 0. Amount Referring Provider ID Value amounts have a decimal followed by two zeroes so by entering 4.00, it will represent 4 days. Referring provider s NPI or Arkansas Medicaid Provider ID. Select the Provider ID from the list. If the ID number is not in the list, double-click in the Referring Provider ID field. A data-entry screen opens. 01/19/12 53

56 Type the Provider ID. Select Save, and then choose Select. Attending Provider ID Attending provider s NPI or Arkansas Medicaid Provider ID. Select the Provider ID from the list. If the NPI is not in the list, double-click in the Attending Provider ID field. A data-entry screen opens. Type the necessary data. Select Save, and then choose Select. 01/19/12 54

57 Header 5 Select the Header 5 tab and enter data into each of the following fields. Admission Date Hour Type Discharge Hour Admit Source TPL Indicator Crossover Indicator Date on which the beneficiary was admitted to the facility. Format: MM/DD/YYYY. Code for the hour at which the beneficiary was admitted to the facility. Code for the priority of the admission. Code for the hour at which the beneficiary was discharged from the facility. Code for the source of the admission. Select the code from the list. If the code is not in the list, double-click in the Admit Source field. A data-entry screen opens. Type the code. (See the National Uniform Billing Committee manual.) Select Save, and then choose Select. If the beneficiary has primary insurance coverage for institutional services, select Y. A TPL tab is added to the form and must be completed. The field will default to N (no). If the beneficiary has Medicare coverage for institutional services, select Y. A Crossover tab is added to the form and must be completed. The field will default to N (no). 01/19/12 55

58 TPL Select the TPL tab (if any) and enter data into each of the following fields. Claim Filing Indicator Code Paid Amount Denial Date Code for the type of other insurance claim being submitted. Total dollar amount paid by the primary insurance. If Paid Amount is 0, date on which the claim was denied by primary insurance. Format: MM/DD/YYYY. Policy Holder Carrier Code Carrier Name Member/ Policy # Last Name First Name Code identifying the insurance carrier the third party liability (TPL) carrier code assigned by the Arkansas Medicaid Program. Select the code from the list. If the code is not in the list, double-click in the Carrier Code field. A data-entry screen opens. Enter a valid carrier code from the most current list found at Select Save, and then choose Select. Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. 01/19/12 56

59 Crossover Select the Crossover tab (if any) and enter data into each of the following fields. Claim Filing Indicator Code Medicare ICN Non Allowed Amount Medicare Paid Amount Adjudication Date Blood Deductible Amount Deductible Amount Coinsurance Amount Code for the type of Medicare claim being submitted. 13-digit claim number (ICN) assigned by Medicare. Total Medicare non-covered dollar amount. Dollar amount paid by Medicare. Date on which Medicare adjudicated the claim. Format: MM/DD/YYYY. Total dollar amount paid by Medicare for blood deductible. Deductible dollar amount that Medicare applied to the claim. Coinsurance dollar amount that Medicare applied to the claim. 01/19/12 57

60 Service Select the Service tab and enter data into each of the following fields. Revenue Code Units Charges Revenue Code that applies to this inpatient stay. Select the Revenue Code from the list. If the Revenue Code is not in the list, double-click in the Revenue Code field. A data-entry screen opens. Type the Revenue Code. Select Save, and then choose Select. Number of days, services, time intervals, or items, depending on the service provided. Total charges related to this revenue code. When you have completed the form, Select Save to save the transaction. OR Select Add to save the transaction and open a new form for data entry. 01/19/12 58

61 837 Institutional Nursing Home Use the 837 Institutional Nursing Home form to file Long Term Care (nursing home) claims. The 837 Institutional Nursing Home form has six tabs: Header 1 Header 2 Header 3 TPL (Third Party Liability, added only when applicable) Crossover (Medicare Crossover, added only when applicable) Service To open the 837 Institutional Nursing Home form On the Forms menu, select 837 Institutional Nursing Home. OR On the toolbar of the main screen, click the 837 Institutional Nursing Home icon. 01/19/12 59

62 Header 1 The 837 Institutional Nursing Home claim form opens with the Header 1 tab on top. To complete Header 1, enter data into each of the following fields. Provider ID Type of Bill NPI or Arkansas Medicaid Provider ID. This ID must be the ID number of a facility. Select the ID number from the list. If the ID number is not in the list, double-click in the Provider ID field. A data-entry screen opens. Type the Provider ID. Select Save, and then choose Select. 3-digit Type of Bill code. Select Type of Bill code from the list. If the code is not in the list, doubleclick in the Type of Bill field. A data-entry screen opens. Type the code. Select Save, and then choose Select. NOTE: Use the type of bill code ending in 8 to void (cancel) a prior claim (indicated by the ICN) and have the payment withheld from future payments. You must complete a voided claim exactly as it was originally submitted for the cancellation to be successful. You can increase your accuracy when voiding claims by copying the original claim, changing the Type of Bill to 8, typing the 13-digit ICN, and saving the transaction. Use a 7 as the third digit of the type of bill to replace a prior claim 01/19/12 60

63 (indicated by the ICN). Copy the original claim, change the third digit of the type of bill to 7, type the 13-digit original ICN, correct the claim and save the transaction. Original Claim # Beneficiary ID Account # Last Name First Name Patient Status Medical Record # If the third digit of the Type of Bill code is 7 or 8, original 13-digit claim number assigned by Arkansas Medicaid/HP. Beneficiary s ID. Select the Beneficiary ID from the list. If the beneficiary s information is already a part of your list, the remaining beneficiary fields are filled automatically. If you want to add the beneficiary to your list, double-click in the Beneficiary ID field. A data-entry screen opens. Type Beneficiary ID. Select Save, and then choose Select. Unique patient ID assigned by your facility. If the beneficiary s information is already a part of your list, this field is filled automatically; however, you can change the data by typing over it. Filled automatically, based on Beneficiary ID. Filled automatically, based on Beneficiary ID. Beneficiary s patient status code. Select the patient status code from the list. If the code is not in the list, double-click in the Patient Status field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Number assigned by you that identifies the beneficiary in your records. Can contain alpha and numeric characters. Optional. Attachment Type Code Transmission Code Control # Code for the title or contents of a document, report, or supporting item for this claim, if applicable. Code that defines the method or format by which reports are to be sent, if applicable. Report transmission code you have assigned to the attachment, if applicable. This code can consist of alpha or numeric characters, or both. 01/19/12 61

64 Header 2 Select the Header 2 tab and enter data into each of the following fields. Admission Date Hour From DOS To DOS Facility Provider ID Facility License # Date on which the beneficiary was admitted to the facility. Format: MM/DD/YYYY. Code for the hour at which the beneficiary was admitted to the facility. Beginning date of service. Format: MM/DD/YYYY. Ending date of service. Format: MM/DD/YYYY. NPI of the facility where the beneficiary resides. Select the Facility Provider ID from the list. If the ID number is not in the list, double-click in the Facility Provider ID field. A data-entry screen opens. Type the Facility Provider ID. Select Save, and then choose Select. Required for all Hospice Long Term Care claims. Filled automatically, based on the Facility Provider ID. 01/19/12 62

65 Header 3 Select the Header 3 tab and enter data into each of the following fields. Diagnosis Codes Primary Other (1 through 8) Admit TPL Indicator Crossover Primary diagnosis code for the visit. Select the code from the list. If the code is not in the list, double-click in the Primary field. A data-entry screen opens. Type the diagnosis code. Select Save, and then choose Select. Additional diagnosis code related to the visit if applicable. Select the additional code from the list. If the code is not in the list, double-click in the field. A data-entry screen opens. Type the necessary code. Select Save, and then choose Select. Diagnosis code for the condition that prompted the beneficiary s admission to the facility. Select the diagnosis code from the list. If the code is not in the list, double-click in the Admit field. A data-entry screen opens. Type the code. Select Save, and then choose Select. If the beneficiary has primary insurance coverage for nursing home services, select Y from the list. A TPL tab is added to the form and must be completed. The field will default to N (no). If the beneficiary has Medicare coverage for nursing home services, 01/19/12 63

66 Indicator select Y from the list. A Crossover tab is added to the form and must be completed. The field will default to N (no). 01/19/12 64

67 TPL Select the TPL tab (if any) and enter data into each of the following fields. Claim Filing Indicator Code Paid Amount Denial Date Code for the type of other insurance claim being submitted. Total dollar amount paid by the primary insurance. If Paid Amount is 0, date on which the claim was denied by primary insurance. Format: MM/DD/YYYY. Policy Holder Carrier Code Carrier Name Member/ Policy # Last Name Code identifying the insurance carrier the third party liability (TPL) carrier code assigned by the Arkansas Medicaid Program. Select from the list. If the code is not in the list, double-click in the Carrier Code field. A data-entry screen opens. Enter a valid carrier code from the most current list found at Select Save, and then choose Select. Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. 01/19/12 65

68 First Name Filled automatically, based on Carrier Code. 01/19/12 66

69 Crossover Select the Crossover tab (if any) and enter data into each of the following fields. Claim Filing Indicator Code Medicare ICN Non Allowed Amount Medicare Paid Amount Adjudication Date Blood Deductible Amount Deductible Amount Coinsurance Amount Code for the type of Medicare claim being submitted. 13-digit claim number (ICN) assigned by Medicare. Total Medicare non-covered dollar amount. Dollar amount paid by Medicare. Date on which Medicare adjudicated the claim. Format: MM/DD/YYYY. Total dollar amount paid by Medicare for blood deductible. Deductible dollar amount that Medicare applied to the claim. Coinsurance dollar amount that Medicare applied to the claim. 01/19/12 67

70 Service Select the Service tab and enter data into each of the following fields. From DOS To DOS Revenue Code Units Charges Beginning date of service. Format: MM/DD/YYYY. Ending date of service. Format: MM/DD/YYYY. Revenue Code that applies to this inpatient stay. Select the Revenue Code from the list. If the Revenue Code is not in the list, double-click in the Revenue Code field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Number of days, services, time intervals, or items, depending on the service provided. Total charges related to this revenue code. When you have completed the form, Select Save to save the transaction. OR Select Add to save the transaction and open a new form for data entry. 01/19/12 68

71 Copying old claims to submit as new claims You can use the Edit All feature to create new claims by copying and editing old claims. 1. Copy one or more previously submitted claims that have F (Finalized) status. To copy one claim, highlight the claim in the list of finalized claims; select Copy; and then select Save. To copy a batch of claims, see Resubmission section of this manual. Each copied claim now has R (Ready to transmit) status. 2. Select Edit All. The Edit All data-entry box opens. 3. Complete the fields From DOS, To DOS, and Units, and then select OK. 4. A system message shows the number of claim forms that will be updated. If the number is correct, select Yes. 5. Review each form that has R status to verify that the billed amount and patient liability are correct for the number of days billed on the claim. Make any necessary corrections. 6. When all claims are correct, select Close. For information about submitting claims, see Communication section of this manual. 01/19/12 69

72 837 Institutional Outpatient Use the 837 Institutional Outpatient form to file claims for outpatient services. The 837 Institutional Outpatient form has six tabs: Header 1 Header 2 Header 3 TPL (Third Party Liability, added only when applicable) Crossover (Medicare Crossover, added only when applicable) Service To open the 837 Institutional Outpatient form On the Forms menu, select 837 Institutional Outpatient. OR On the toolbar of the main screen, click the 837 Institutional Outpatient icon. 01/19/12 70

73 Header 1 The 837 Institutional Outpatient claim form opens with the Header 1 tab on top. To complete Header 1, enter data into each of the following fields. Provider ID Type of Bill Billing provider s NPI or Arkansas Medicaid Provider ID. Select the Provider ID from the list. If the ID number is not in the list, double-click in the Provider ID field. A data-entry screen opens. Type the Provider ID. Select Save, and then choose Select. 3-digit Type of Bill code. Select the code from the list. If the code is not in the list, double-click in the Type of Bill field. A data-entry screen opens. Type the Type of Bill code. Select Save, and then choose Select. NOTE: Use the type of bill code ending in 8 to void (cancel) a prior claim (indicated by the ICN) and have the payment withheld from future payments. You must complete a voided claim exactly as it was originally submitted for the cancellation to be successful. You can increase your accuracy when voiding claims by copying the original claim, changing the Type of Bill to 8, typing the 13-digit ICN, and saving the transaction. Use a 7 as the third digit of the type of bill to replace a prior claim (indicated by the ICN). Copy the original claim, change the third digit of the type of bill to 7, type the 13-digit original ICN, correct the claim 01/19/12 71

74 and save the transaction. Original Claim # Beneficiary ID Account # Last Name First Name From DOS To DOS Medical Record # Prior Authorization If the third digit of the Type of Bill code is 7 or 8, original 13-digit claim number assigned by Arkansas Medicaid/HP. Beneficiary s ID. Select the Beneficiary ID from the list. If the beneficiary s information is already a part of your list, the remaining beneficiary fields are filled automatically. If you want to add the beneficiary to your list, double-click in the Beneficiary ID field. A data-entry screen opens. Type the Beneficiary ID. Select Save, and then choose Select. Unique patient ID assigned by your facility. If the beneficiary s information is already a part of your list, this field is filled automatically; however, you can change the data by typing over it. Filled automatically, based on Beneficiary ID. Filled automatically, based on Beneficiary ID. Beginning date of service. Format: MM/DD/YYYY. Ending date of service. Format: MM/DD/YYYY. Number assigned by you that identifies the beneficiary in your records. Can contain alpha and numeric characters. Optional. 10-digit prior authorization number assigned by Arkansas Medicaid, if applicable. Attachment Type Code Transmission Code Control # Code for the title or contents of a document, report, or supporting item for this claim, if applicable. Code that defines the method or format by which reports are to be sent, if applicable. Report transmission code you have assigned to the attachment, if applicable. This code can consist of alpha or numeric characters, or both. 01/19/12 72

75 Header 2 Select the Header 2 tab and enter data into each of the following fields. Diagnosis Codes Primary Other (1 through 8) Emergency Attending Provider ID Primary diagnosis code for the visit. Select the diagnosis code from the list. If the code is not in the list, double-click in the Primary field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Additional diagnosis code related to the visit, if applicable. Select the code from the list. If the code is not in the list, double-click in the field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Diagnosis code describing an injury, poisoning, or adverse effect for which the service is being billed. Select the code from the list. If the code is not in the list, double-click in the Emergency field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Attending provider s NPI or Arkansas Medicaid Provider ID number. Select the Provider ID from the list. If the ID number is not in the list, double-click in the Attending Provider ID field. A data-entry screen opens. 01/19/12 73

76 Type the Provider ID. Select Save, and then choose Select. Referring Provider ID Operating Physician ID Referring provider s NPI or Arkansas Medicaid Provider ID number. Select the Provider ID number from the list. If the ID number is not in the list, double-click in the Referring Provider ID field. A data-entry screen opens. Type the Provider ID. Select Save, and then choose Select. Operating physician s NPI or Arkansas Medicaid Provider ID number. Select the Provider ID from the list. If the ID number is not in the list, double-click in the Operating Physician ID field. A data-entry screen opens. Type the Provider ID. Select Save, and then choose Select. Admission Date Hour Discharge Hour Date on which the beneficiary was admitted to the facility. Format: MM/DD/YYYY. Code for the hour at which the beneficiary was admitted to the facility. Code for the hour at which the beneficiary was discharged from the facility. 01/19/12 74

77 Header 3 Select the Header 3 tab and enter data into each of the following fields. Condition Codes Condition Codes (1 through 7) Code for a condition. (See the National Uniform Billing Committee manual.) Select the code from the list. If the code is not in the list, double-click in a Condition Code field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Value Codes/Amounts (1 through 12) Code Amount TPL Indicator Crossover Code specifying the type of service from a particular industry. (See the National Uniform Billing Committee manual.) Select the code from the list. If the code is not in the list, double-click in the Value Code field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Dollar amount corresponding to the value code. If the beneficiary has primary insurance coverage for outpatient services, select Y from the list. A TPL tab is added to the form and must be completed. The field will default to N (no). If the beneficiary has Medicare coverage for outpatient services, select Y 01/19/12 75

78 Indicator from the list. A Crossover tab is added to the form and must be completed. The field will default to N (no). 01/19/12 76

79 TPL Select the TPL tab (if any) and enter data into each of the following fields. Claim Filing Indicator Code Paid Amount Denial Date Code for the type of other insurance claim being submitted. Total dollar amount paid by the primary insurance. If Paid Amount is 0, date on which the claim was denied by primary insurance. Format: MM/DD/YYYY. Policy Holder Carrier Code Carrier Name Member/ Policy # Last Name First Name Code identifying the insurance carrier the third party liability (TPL) carrier code assigned by the Arkansas Medicaid Program. Select the code from the list. If the code is not in the list, double-click in the Carrier Code field. A data-entry screen opens. Enter a valid carrier code from the most current list found at Select Save, and then choose Select. Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. 01/19/12 77

80 Crossover Select the Crossover tab (if any) and enter data into each of the following fields. Medicare ICN Allowed Amount Non Allowed Amount Medicare Paid Amount Adjudication Date Blood Deductible Amount Deductible Amount Coinsurance Amount 13-digit claim number (ICN) assigned by Medicare. Medicare-allowed dollar amount. Total Medicare non-covered dollar amount. Dollar amount paid by Medicare. Date on which Medicare adjudicated the claim. Format: MM/DD/YYYY. Total dollar amount paid by Medicare for blood deductible. Deductible dollar amount that Medicare applied to the claim. Coinsurance dollar amount that Medicare applied to the claim. 01/19/12 78

81 Service Select the Service tab and enter data into each of the following fields. Date of Service Revenue Code Procedure Modifiers (1 through 4) Units Charges Date on which services were provided. Format: MM/DD/YYYY. Revenue Code that applies to this inpatient stay. Select the code from the list. If the Revenue Code is not in the list, double-click in the Revenue Code field. A data-entry screen opens. Type the code. Select Save, and then choose Select. 5-digit American Dental Association procedure code. Select the code from the list. If the procedure code is not in the list, double-click in the Procedure field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Code(s) that further define the procedure code. Select the code(s) from the list(s). If the code is not in the list, double-click in a modifier field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Number of days, services, time intervals, or items, depending on the service provided. Total charges for the services rendered. 01/19/12 79

82 RX Indicator Select Yes from the list if the beneficiary received medication during the service. An RX tab is added to the form and must be completed. The field will default to N (no). Only one RX may be entered per claim detail. A new detail line must be added on the Service tab in order to enter a second RX. When you have completed the form, Select Save to save the transaction. OR Select Add to save the transaction and open a new form for data entry. 01/19/12 80

83 RX Select the RX tab (if any) and enter data into each of the following fields. Drug Identification NDC Unit of Measurement Quantity RX/Link # 11-digit NDC (National Drug Code) for any prescription drug dispensed in the office setting to the beneficiary. Code for the units of measure in which the prescription drug was dispensed. Number of units dispensed of the prescription drug. The prescription or link number for the NDC. This field is required when administering a compound drug. Enter the same link or Rx number on each detail that represents the compound drug. When you have completed the form, Select Save to save the transaction. OR Select Add to save the transaction and open a new form for data entry. 01/19/12 81

84 837 Professional Medicaid Use the 837 Professional Medicaid form to file claims for medical services. The 837 Professional Medicaid form has eight tabs: Header 1 Header 2 Header 3 TPL (Third Party Liability, added only when applicable) Crossover (Medicare Crossover, added only when applicable) Service 1 Service 2 NET (Non-Emergency Transportation, added only when applicable) RX (Prescription Drug, added only when applicable) To open the 837 Professional Medicaid form On the Forms menu, select 837 Professional Medicaid. OR On the toolbar of the main screen, click the 837 Professional Medicaid icon 01/19/12 82

85 Header 1 The 837 Professional Medicaid claim form opens with the Header 1 tab on top. To complete Header 1, enter data into each of the following fields. Provider ID Claim Frequency Billing provider s NPI or Arkansas Medicaid Provider ID. Select the Provider ID from the list. If the ID number is not in the list, double-click in the Provider ID field. A data-entry screen opens. Type the Provider ID. Select Save, and then choose Select. Claim Frequency code. Select 1 to submit an original claim. Select 7 to replace a prior claim (indicated by the ICN). Copy the original claim, change the Claim Frequency to 7, type the 13-digit original ICN, correct the claim, and save the transaction. NOTE: To successfully adjust a claim, you cannot alter the provider ID, beneficiary ID, claim type, or number of details. A claim can only be adjusted after it is listed as paid on a remittance advice. It cannot be adjusted during the week that it is originally submitted. Select 8 to void (cancel) a prior claim (indicated by the ICN) and have the payment withheld from future payments. NOTE: You must complete a voided claim exactly as it was originally submitted for the cancellation to be successful. You can increase your accuracy when voiding claims by copying the original claim, 01/19/12 83

86 changing the Claim Frequency to 8, typing the 13-digit ICN, and saving the transaction. Original Claim # Beneficiary ID Account # Last Name First Name If the third digit of the Type of Bill code is 7 or 8, original 13-digit claim number assigned by Arkansas Medicaid/HP. Beneficiary s ID. Select the ID from the list. If the beneficiary s information is already a part of your list, the remaining beneficiary fields are filled automatically. If you want to add the beneficiary to your list, double-click in the Beneficiary ID field. A data-entry screen opens. Type the ID. Select Save, and then choose Select. Unique patient ID assigned by your facility. If the beneficiary s information is already a part of your list, this field is filled automatically; however, you can change the data by typing over it. Filled automatically, based on Beneficiary ID. Filled automatically, based on Beneficiary ID. Attachment Type Code Transmission Code Control # Code for the title or contents of a document, report, or supporting item for this claim, if applicable. Code that defines the method or format by which reports are to be sent, if applicable. Report transmission code you have assigned to the attachment, if applicable. This code can consist of alpha or numeric characters, or both. 01/19/12 84

87 Header 2 Select the Header 2 tab and enter data into each of the following fields. Diagnosis Codes Primary Other (1 through 7) Referring Provider ID Primary diagnosis code for the visit. Select the code from the list. If the code is not in the list, double-click in the Primary field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Additional diagnosis code related to the visit, if applicable. Select the code from the list. If the code is not in the list, double-click in the field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Referring provider s NPI or Arkansas Medicaid Provider ID. If the provider is eligible for an NPI, the NPI must be used here. If the provider is not eligible for an NPI, the provider s Arkansas Medicaid provider identification number is used. Prior Auth Place of Service 10-digit prior authorization number assigned by Arkansas Medicaid, if applicable. 2-digit code for the place at which service was delivered. 01/19/12 85

88 Hospital Admit Date Date Last Seen Onset of Current Illness Date Date on which the beneficiary was admitted to the facility. Format: MM/DD/YYYY. Date on which the beneficiary was last seen. Date on which the current illness began. Facility Name NPI Address 1 Address 2 City State Zip Name of facility where services were rendered. NPI or Arkansas Medicaid Provider ID of facility where the services were rendered. Street address of facility where services were rendered. Second street address line if needed. City where services were rendered. 2-character postal abbreviation for state. First 5 digits of zip code are required. Space is available for +4 digits. 01/19/12 86

89 Header 3 Select the Header 3 tab and enter data into each of the following fields. Related Causes. If the services were made necessary by an accident or employment-related incident, complete the following fields. 1 through 3 Select the code(s) for the appropriate related cause(s). Incident Date Accident State Special Program Code If you selected a code for 1, 2, or 3, then the date of the incident is required. Format: MM/DD/YYYY. Code for the state in which the accident occurred. Code for the special program under which the services were provided. EPSDT Referral. If the services were rendered as the result of an EPSDT referral, you must complete the following fields. Certification Condition Indicator Condition Indicator Indicates whether the beneficiary received an EPSDT referral. The field will default to blank (no). From the list, select the code for the beneficiary s referral status. 01/19/12 87

90 Therapy Service School District TPL Indicator Crossover Indicator NET Indicator Category of Care for occupational, physical, and speech therapy claims. School district in which the beneficiary resides. If the beneficiary has primary insurance coverage for professional services, select Y from the list. A TPL tab is added to the form and must be completed. The field will default to N (no). If the beneficiary has Medicare coverage for professional services, select Y from the list. A Crossover tab is added to the form and must be completed. The field will default to N (no). If the beneficiary used Non-Emergency Transportation Services in connection with this claim, select Y from the list. A NET tab is added to the form and must be completed. The field will default to N (no). 01/19/12 88

91 TPL Select the TPL tab (if any) and enter data into each of the following fields. Claim Filing Indicator Code Paid Amount Denial Date Code for the type of other insurance claim being submitted. Total dollar amount paid by the primary insurance. If Paid Amount is 0, date on which the claim was denied by primary insurance. Format: MM/DD/YYYY. Policy Holder Carrier Code Carrier Name Member/ Policy # Code identifying the insurance carrier the third party liability (TPL) carrier code assigned by the Arkansas Medicaid Program. Select the code from the list. If the code is not in the list, double-click in the Carrier Code field. A data-entry screen opens. Enter a valid carrier code from the most current list found at Select Save, and then choose Select. Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. 01/19/12 89

92 Last Name First Name Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. 01/19/12 90

93 Crossover Select the Crossover tab (if any) and enter data into each of the following fields. Medicare ICN Medicare Paid Amount Adjudication Date Deductible Amount Coinsurance Amount 13-digit claim number (ICN) assigned by Medicare. Dollar amount paid by Medicare. Date on which Medicare adjudicated the claim. Format: MM/DD/YYYY. Deductible dollar amount that Medicare applied to the claim. Coinsurance dollar amount that Medicare applied to the claim. 01/19/12 91

94 Service 1 Select the Service 1 tab and enter data into each of the following fields. Performing Provider ID From DOS To DOS Place of Service Procedure Performing provider s NPI or Arkansas Medicaid Provider ID number, if different than the billing provider s ID number. Select the ID number from the list. If the ID number is not in the list, double-click in the Performing Provider ID field. A data-entry screen opens. Type the ID. Select Save, and then choose Select. If the performing provider s ID number is the same as the billing provider s ID number, leave this field blank. Beginning date of service. Format: MM/DD/YYYY. Ending date of service. Format: MM/DD/YYYY. Place of service for this detail, if different than the place of service listed in Header 2. Select from the list the two-digit code for the place at which service was delivered. If the code is not in the list, double-click in the Place of Service field. A data-entry screen opens. Type the code. Select Save, and then choose Select. If the place of service is the same as that listed in Header 2, leave this field blank. CPT or HCPCS procedure code. 01/19/12 92

95 If the procedure code is not in the list, double-click in the Procedure field. A data-entry screen opens. Type the procedure code. Select Save, and then choose Select. Modifiers (1 through 4) Diagnosis Ptr Unit of Measure Units Fund Code Charges Code(s) that further define the procedure code. Select the code(s) from the list(s). If the code is not in the list, double-click in a modifier field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Detail diagnosis number for this service if applicable. Unit of measure for this service. Number of days, services, time intervals, or items, depending on the service provided. Provider s and beneficiary s non-medicaid fund code assigned by the Developmental Disabilities Services office. Provider and beneficiary must be eligible for the same plan code. Dollar amount charged for services, procedures, or products. 01/19/12 93

96 Service 2 Select the Service 2 tab and enter data into each of the following fields. Emergency Indicator EPSDT Family Planning RX Indicator Select Yes from the list if the services were rendered due to an emergency. The field will default to blank (No). Select Yes from the list if the services were rendered as a result of an EPSDT screening. The field will default to blank (No). Select Yes from the list if the services were rendered in connection with family planning. The field will default to blank (No). Select Yes from the list if the beneficiary received medication during the service. An RX tab is added to the form and must be completed. The field will default to blank (No). Only one RX may be entered per claim detail. A new detail line must be added on the Service tab in order to enter a second RX. 01/19/12 94

97 NET Select the NET tab (if any) and enter data into each of the following fields. Destination Provider Request Date Within Service Region Others Riding Transportation Appointment After Hours Lookup Military Destination provider s NPI or Arkansas Medicaid Provider ID. Select the ID from the list. If the NPI is not in the list, double-click in the Provider ID field. A data-entry screen opens. Type the ID. Select Save, and then choose Select. Date the NET service was requested by beneficiary. Format: MMDDYYYY. Indicate whether the service was provided within the region assigned to the broker. If someone other than the beneficiary was transported by NET provider, identify that individual. Values: N = None E = Escort I = Inpatient visit by parent/guardian Mode of transportation. Values: Bus, Car, Taxi, Van. Indicate whether appointment was after business hours. All time must be reported in military format. If you are not sure how to express time in military format, click the down-pointing arrow to reveal a 01/19/12 95

98 Time conversion table. Original Destination Scheduled Pick Up Time Actual Pick Up Time Actual Drop Off Time Time scheduled to pick up beneficiary or other rider at original destination. Use military format. Time beneficiary or other rider was actually picked up at original destination. Use military format. Time beneficiary or other rider was actually dropped off at original destination. Use military format. Destination Provider Appointment Time Actual Drop Off Time Actual Pick Up Time Time of beneficiary s appointment with destination provider. Use military format. Time beneficiary or other rider was actually dropped off at destination provider s facility. Use military format. Time beneficiary or other rider was actually picked up at destination provider s facility. Use military format. When you have completed the form, Select Save to save the transaction. OR Select Add to save the transaction and open a new form for data entry. 01/19/12 96

99 RX Select the RX tab (if any) and enter data into each of the following fields. Drug Identification NDC Unit of Measure Quantity RX/Link # The 11-digit NDC (National Drug Code) for any prescription drug dispensed in the office setting to the beneficiary. Code for the units of measure in which the prescription drug was dispensed. Number of units dispensed of the prescription drug. The prescription or link number for the NDC. This field is required when administering a compound drug. Enter the same link or Rx number on each detail that represents the compound drug. When you have completed the form, Select Save to save the transaction. OR Select Add to save the transaction and open a new form for data entry. 01/19/12 97

100 837 Professional BreastCare Use the 837 Professional BreastCare form to file claims for BreastCare services. The 837 Professional BreastCare form has four tabs: Header 1 Header 2 TPL (Third Party Liability, added only when applicable) Service 1 Service 2 To open the 837 Professional BreastCare form On the Forms menu, select 837 Professional BreastCare. OR On the toolbar of the main screen, click the 837 Professional BreastCare icon. 01/19/12 98

101 Header 1 The 837 Professional BreastCare claim form opens with the Header 1 tab on top. To complete Header 1, enter data into each of the following fields. Provider ID Claim Frequency Original Claim # Billing provider s NPI or Arkansas Medicaid ID number.. Select the ID from the list. If the ID is not in the list, double-click in the Provider ID field. A data-entry screen opens. Type the Provider ID. Select Save, and then choose Select. Claim Frequency code. Select 1 to submit an original claim. Select 7 to replace a prior claim (indicated by the ICN). Copy the original claim, change the Claim Frequency to 7, type the 13-digit original ICN, correct the claim, and save the transaction. NOTE: To successfully adjust a claim, you cannot alter the provider ID, client ID, claim type, or number of details. A claim can only be adjusted after it is listed as paid on a remittance advice. It cannot be adjusted during the week that it is originally submitted. Select 8 to void (cancel) a prior claim (indicated by the ICN) and have the payment withheld from future payments. NOTE: You must complete a voided claim exactly as it was originally submitted for the cancellation to be successful. You can increase your accuracy when voiding claims by copying the original claim, changing the Claim Frequency to 8, typing the 13- digit ICN, and saving the transaction. If the third digit of the Type of Bill code is 8, original 13-digit claim number 01/19/12 99

102 assigned by Arkansas Medicaid/HP. Client ID Account # Last Name First Name Client s ID. If the client s information is already a part of your list, the remaining client fields are filled automatically. Select the ID from the list. If you want to add the client to your list, doubleclick in the Client ID field. A data-entry screen opens. Type the client ID. Select Save, and then choose Select. Unique patient ID assigned by your facility. If the client s information is already a part of your list, this field is filled automatically; however, you can change the data by typing over it. Filled automatically, based on Client ID. Filled automatically, based on Client ID. Attachment Type Code Transmission Code Control # Code for the title or contents of a document, report, or supporting item for this claim, if applicable. Code that defines the method or format by which reports are to be sent, if applicable. Report transmission code you have assigned to the attachment, if applicable. This code can consist of alpha or numeric characters, or both. 01/19/12 100

103 Header 2 Select the Header 2 tab and enter data into each of the following fields. Diagnosis Codes Primary Other( 1 through 7) Referring Provider ID Place of Service Prior Authorization TPL Indicator Primary diagnosis code for the visit. Select the code from the list. If the code is not in the list, double-click in the Primary field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Additional diagnosis code related to the visit, if applicable. Select the code from the list. If the code is not in the list, double-click in the field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Referring provider s NPI or Arkansas Medicaid ID number. Select the ID from the list. If the ID is not in the list, double-click in the Referring Provider ID field. A data-entry screen opens. Type the ID number. Select Save, and then choose Select. 2-digit code for the place at which service was delivered. 10-digit prior authorization number assigned by the Arkansas Department of Health, if applicable. If the client has primary insurance coverage for BreastCare services, select Y from the list. A TPL tab is added to the form and must be 01/19/12 101

104 completed. The field will default to N (no). Hospital Admit Date Date on which the client was admitted to the facility. Format: MM/DD/YYYY. Facility Name Address 1 Address 2 City State Zip Name of facility where services were rendered. Street address of facility where services were rendered. Second street address line, if needed. City where services were rendered. 2-character postal abbreviation for state. First 5 digits of zip code are required. Space is available for +4 digits. 01/19/12 102

105 TPL Select the TPL tab (if any) and enter data into each of the following fields. Claim Filing Indicator Code Paid Amount Denial Date Code for the type of other insurance claim being submitted. Total dollar amount paid by the primary insurance. If Paid Amount is 0, date on which the claim was denied by primary insurance. Format: MM/DD/YYYY. Policy Holder Carrier Code Carrier Name Member/ Policy # Last Name First Name Code identifying the insurance carrier the third party liability (TPL) carrier code assigned by the Arkansas Medicaid Program. Select the code from the list. If the code is not in the list, double-click in the Carrier Code field. A data-entry screen opens. Enter a valid carrier code from the most current list found at Select Save, and then choose Select. Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. Filled automatically, based on Carrier Code. 01/19/12 103

106 Service 1 Select the Service 1 tab and enter data into each of the following fields. Performing Provider ID From DOS To DOS Place of Service Procedure Performing provider s ID number, if different than the billing provider s ID number. Select the Provider ID from the list. If the ID number is not in the list, double-click in the Performing Provider ID field. A data-entry screen opens. Type the Provider ID. Select Save, and then choose Select. If the performing provider s ID number is the same as the billing provider s ID number, leave this field blank. Beginning date of service. Format: MM/DD/YYYY. Ending date of service. Format: MM/DD/YYYY. Place of service for this detail, if different than the place of service listed in Header 2. Select the 2-digit code from the list for the place at which service was delivered. If the code is not in the list, double-click in the Place of Service field. A data-entry screen opens. Type the code. Select Save, and then choose Select. If the place of service is the same as that listed in Header 2, leave this field blank. CPT or HCPCS procedure code. Select the code from the list. If the procedure code is not in the list, double-click in the Procedure field. A data-entry screen opens. Type the 01/19/12 104

107 procedure code. Select Save, and then choose Select. Modifiers (1 through 4) Diagnosis Ptr Units Charges Code(s) that further define the procedure code. Select the code(s) from the list(s). If the code is not in the list, double-click in a modifier field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Detail diagnosis number for this service, if applicable. Number of days, services, time intervals, or items, depending on the service provided. Dollar amount charged for services, procedures, or products. 01/19/12 105

108 Service 2 Select the Service 2 tab and enter data into each of the following fields. Result Code Recommendation Code Months for STFU Pap Smear Adequacy Code Result code for either breast or cervical procedures. See BreastCare billing manual for code criteria. Recommendation code for either breast or cervical procedures. See BreastCare billing manual for code criteria. If Recommendation Code is 2, number of months required for short term follow-up. Code for pap smear. See BreastCare billing manual for criteria. When you have completed the form, Select Save to save the transaction. OR Select Add to save the transaction and open a new form for data entry. 01/19/12 106

109 NCPDP Pharmacy Use the NCPDP (National Council for Prescription Drug Programs) Pharmacy form to file claims for prescription drugs. The NCPDP Pharmacy form has seven tabs: Header RX Partial RX TPL (Third Party Liability, added only when applicable) Compound (added only when applicable) Clinical DUR/PPS & Coupon To open the NCPDP Pharmacy form On the Forms menu, select NCPDP Pharmacy. OR On the toolbar of the main screen, click the NCPDP Pharmacy icon. 01/19/12 107

110 Header The NCPDP Pharmacy claim form opens with the Header tab on top. To complete the Header, enter data into each of the following fields. Provider ID Cardholder ID Last Name First Name Patient Last Name Patient First Name Patient DOB Billing provider s NPI or Arkansas Medicaid Provider ID. Select the ID from the list. If the ID is not in the list, double-click in the Provider ID field. A data-entry screen opens. Type the ID. Select Save, and then choose Select. Beneficiary s Arkansas Medicaid ID number. If the beneficiary s information is already a part of your list, the remaining beneficiary fields are filled automatically. Select the cardholder ID from the list. If you want to add the beneficiary to your list, double-click in the Cardholder ID field. A data-entry screen opens. Type the ID. Select Save, and then choose Select. Filled automatically, based on Cardholder ID. Filled automatically, based on Cardholder ID. Enter the last name of the patient receiving the prescription. Enter the first name of the patient receiving the prescription. Enter the patient s date of birth. 01/19/12 108

111 Date of Service Place of Service Compound Code Other Coverage Code Patient Gender Pregnancy Indicator Medicaid Indicator Current date of service. If service was rendered on a prior date, type the date. The field will automatically fill with the current date. Format: MM/DD/YYYY. 2-digit code for the place at which service was delivered. If the prescription is a compound, select 2 from the list. A Compound tab is added to the form and must be completed. The field will default to 1 (not a compound). If the beneficiary has other coverage for prescription drugs, select the applicable code. A TPL tab is added to the form and must be completed. The field will default to 01 (no other coverage). Gender of the patient. Code to indicate whether or not the patient is pregnant. Required if pregnancy could result in different coverage, pricing, or patient financial responsibility. Abbreviation of the state in which the beneficiary has Medicaid coverage. Required in special situations when State issues instructions. For example, to identify beneficiaries of another state relocated to AR because of natural disaster. 01/19/12 109

112 RX Select the RX tab and enter data into each of the following fields. Prescriber ID Prescribing provider s NPI or Arkansas Medicaid Provider ID. If the provider is eligible for an NPI, the NPI must be used here. Prescription # NDC Quantity Fill Number Days Supply Level of Service DAW Code Identification number of the prescription being filled. 11-digit NDC (National Drug Code) for any prescription drug dispensed to the beneficiary. If the NDC is not in the list, double-click in the NDC field. A data-entry screen opens. Type the NDCa. Select Save, and then choose Select. Number of units dispensed of the prescription drug. Number of times the prescription has been filled. For example: the original fill is 00, the first refill is 01, the second refill is 02, etc. Number of days supply of the prescription being filled. Level of service provided when administering this prescription to the beneficiary. If the prescriber instructed Dispense As Written, select from the list the code indicating how those instructions were followed. The field will default 01/19/12 110

113 to 0 (no product selection indicated). Ingredient Cost Usual & Customary Date Prescription Written Basis of Cost Determination Total cost of all drugs in the detail. For compound drug claims, it is the system-generated ingredient cost for the metric decimal quantity of the product included in the compound mixture indicated in Compound Ingredients Ingredient Quantity. Total price being billed from all sources and including all fees, including ingredient cost and dispensing fee. Enter the date the prescription was written/issued. Enter a code indicating by which method Ingredient Cost submitted was calculated. 01/19/12 111

114 Partial RX Select the Partial RX tab (if any) and enter data into each of the following fields. Partial Fills Dispensing Status Code showing whether quantity dispensed is a partial fill or completion of a partial fill. The field will default to blank (not specified). If Dispensing Status is P, complete the following fields. Quantity intended Days Supply Intended Metric decimal quantity of medication that would have been dispensed on original filling if sufficient inventory were available. Days supply of medication that would have been dispensed on original filling if sufficient inventory were available. If Dispensing Status is C, complete the following fields. Associated RX Reference # Associated RX Service Date Original RX NDC Prescription reference number to which the service is related. Date of Associated RX Reference #. Format: MM/DD/YYYY. 11-digit NDC (National Drug Code) for the product originally prescribed for the beneficiary. If the NDC is not in the list, double-click in the Original RX NDC field. A 01/19/12 112

115 data-entry screen opens. Type the necessary data. Select Save, and then choose Select. Original RX Quantity Metric decimal quantity of medication originally prescribed for the beneficiary. 01/19/12 113

116 TPL Select the TPL tab (if any) and enter data into each of the following fields. 1) Amount paid Dollar amount paid for the prescription by other insurance carrier billed before Arkansas Medicaid. Denial Date If 1) Amount Paid is 0, date on which the claim was denied by primary insurance. Format: MM/DD/YYYY. 2) Amount paid Dollar amount paid for the prescription by other insurance carrier billed before Arkansas Medicaid. Denial Date If 2) Amount Paid is 0, date on which the claim was denied by primary insurance. Format: MM/DD/YYYY. 3) Amount paid Dollar amount paid for the prescription by other insurance carrier billed before Arkansas Medicaid. Denial Date If 3) Amount Paid is 0, date on which the claim was denied by primary insurance. Format: MM/DD/YYYY. 01/19/12 114

117 Compound Select the Compound tab (if any) and enter data into each of the following fields. Dosage Form Dispensing Unit Ind Dosage Route Process Compound for Approved Ingredients Code for the form of the compound mixture. NCPDP standard product billing code for the quantity measurement. Code for the route of administration of the complete compound mixture. Code for whether payment is accepted for covered ingredients only. The field will default to blank (no). Compound Ingredients NDC Ingredient Quantity Ingredient Cost 11-digit NDC (National Drug Code) for the product included in the compound mixture. Select the NDC from the list. If the NDC is not in the list, double-click in the NDC field. A data-entry screen opens. Type the NDC. Select Save, and then choose Select. Amount expressed in metric decimal units of the product included in the compound mixture. Ingredient cost for the metric decimal quantity of the product included in the compound mixture (shown in Ingredient Quantity field). 01/19/12 115

118 Clinical Select the Clinical tab and enter data into each of the following fields. Diagnosis Code Diagnosis code related to the prescription, if applicable. Select the code from the list. If the code is not in the list, double-click in the Diagnosis Code field. A data-entry screen opens. Type the code. Select Save, and then choose Select. Measurement (1 through 3) Date Time Dimension Unit Value Date on which clinical information was collected. Time at which clinical information was collected. Code for the clinical domain of Measurement Value. Code for the unit of measure used with the clinical information. Numeric value associated with Unit. 01/19/12 116

119 DUR/PPS & Coupon Select the DUR/PPS & Coupon tab and enter data into each of the following fields. DUR/PPS Reason Professional Result Code that identifies the type of utilization conflict detected. The field will default to blank (no conflict). If Reason is not blank, select the code from the list for the pharmacist s intervention. The field will default to blank (not applicable). If Professional is not blank, select the code from the list for the outcome of the pharmacist s intervention. Coupon Coupon # Coupon Type Coupon Value Amount Unique serial number assigned to the prescription coupon. If Coupon Type is not known at the time claim is submitted, do not send Coupon data. Both Coupon # and Coupon Type must be complete for Coupon to be processed. Code for type of coupon being used. If Coupon # is not known at the time claim is submitted, do not send Coupon data. Both Coupon # and Coupon Type must be complete for Coupon to be processed. Dollar amount of coupon used for this prescription. 01/19/12 117

120 When you have completed the form, Select Save to save the transaction. OR Select Add to save the transaction and open a new form for data entry. You can then use the Batch Submission feature to submit a number of forms at the same time. (For more information, see Sending transactions.) 01/19/12 118

121 NCPDP Pharmacy Reversal Use the NCPDP Pharmacy Reversal form to void a previously submitted pharmacy claim. The NCPDP Pharmacy Reversal form has two tabs: Header Service To open the NCPDP Pharmacy Reversal form On the Forms menu, select NCPDP Pharmacy Reversal. OR On the toolbar of the main screen, click the NCPDP Pharmacy Reversal icon. 01/19/12 119

122 Header The NCPDP Pharmacy Reversal claim form opens with the Header tab on top. To complete the Header, enter data into each of the following fields. Provider ID Date of Service Compound Code Billing provider s NPI or Arkansas Medicaid Provider ID. Select the ID from the list. If the ID number is not in the list, double-click in the Provider ID field. A data-entry screen opens. Type the ID. Select Save, and then choose Select. Date of service. Field will automatically fill with current date. If services were rendered on a prior date, type the date. Format: MM/DD/YYYY. If the prescription is a compound, select 2 from the list. A Compound tab is added to the form and must be completed. The field will default to1 (not a compound). 01/19/12 120

123 Service Select the Service tab and enter data into each of the following fields. Prescription # NDC Identification number of the prescription being filled. 11-digit NDC (National Drug Code) for any prescription drug dispensed to the beneficiary. Select the NDC from the list. If the NDC is not in the list, double-click in the NDC field. A data-entry screen opens. Type the NDC. Select Save, and then choose Select. When you have completed the form, Select Save to save the transaction. OR Select Add to save the transaction and open a new form for data entry. You can then use the Batch Submission feature to submit a number of forms at the same time. For more information, see Sending transactions. 01/19/12 121

124 Long Term Care Census Use the Long Term Care Census form to submit census data for a long term care facility. The Long Term Care Census form has one tab: Census. To open the Long Term Care Census form On the Forms menu, select LTC Census. OR On the toolbar of the main screen, click the LTC Census icon. 01/19/12 122

125 Census The Long Term Care Census form opens to the Census tab. To complete Census, enter data into each of the following fields. Provider ID Census Date Billing provider s NPI or Arkansas Medicaid Provider ID. Select the Provider ID from the list. If the ID number is not in the list, double-click in the Provider ID field. A data-entry screen opens. Type the ID. Select Save, and then choose Select. Date on which census was taken. Format: MM/YYYY. Medicaid SNF ICF1 ICF2 ICF3 ICFMR Number of Medicaid-eligible patients in the nursing home when the census was taken whose level of care was Skilled Nursing Facility. Number of Medicaid-eligible patients in the nursing home when the census was taken whose level of care was Intermediate Care Facility Level 1. Number of Medicaid-eligible patients in the nursing home when the census was taken whose level of care was Intermediate Care Facility Level 2. Number of Medicaid-eligible patients in the nursing home when the census was taken whose level of care was Intermediate Care Facility Level 3. Number of Medicaid-eligible patients in the nursing home when the census was taken whose level of care was Intermediate Care Facility Mentally Retarded. 01/19/12 123

126 Non Classified Hospice Number of Medicaid-eligible patients in the nursing home when the census was taken whose level of care was Non Classified. Number of Medicaid-eligible patients in the nursing home when the census was taken whose level of care was Hospice. Pending SNF ICF1 ICF2 ICF3 ICFMR Non Classified Hospice Number of Medicaid applications pending for patients who were in the nursing home when the census was taken whose level of care was Skilled Nursing Facility. Number of Medicaid applications pending for patients who were in the nursing home when the census was taken whose level of care was Intermediate Care Facility Level 1. Number of Medicaid applications pending for patients who were in the nursing home when the census was taken whose level of care was Intermediate Care Facility Level 2. Number of Medicaid applications pending for patients who were in the nursing home when the census was taken whose level of care was Intermediate Care Facility Level 3. Number of Medicaid applications pending for patients who were in the nursing home when the census was taken whose level of care was Intermediate Care Facility Mentally Retarded. Number of Medicaid applications pending for patients who were in the nursing home when the census was taken whose level of care was Non Classified. Number of Medicaid applications pending for patients who were in the nursing home when the census was taken whose level of care was Hospice. Non Medicaid SNF ICF1 ICF2 Number of patients in the nursing home who were not eligible for Medicaid when the census was taken whose level of care was Skilled Nursing Facility. Include all other non-medicaid patients. For example, those who receive benefits from Medicare, VA, or private insurance. Number of patients in the nursing home who were not eligible for Medicaid when the census was taken whose level of care was Intermediate Care Facility Level 1. Include all other non-medicaid patients. For example, those who receive benefits from Medicare, VA, or private insurance. Number of patients in the nursing home who were not eligible for Medicaid when the census was taken whose level of care was Intermediate Care Facility Level 2. Include all other non-medicaid patients. For example, those who receive benefits from Medicare, VA, or 01/19/12 124

127 private insurance. ICF3 ICFMR Non Classified Hospice Number of patients in the nursing home who were not eligible for Medicaid when the census was taken whose level of care was Intermediate Care Facility Level 3. Include all other non-medicaid patients. For example, those who receive benefits from Medicare, VA, or private insurance. Number of patients in the nursing home who were not eligible for Medicaid when the census was taken whose level of care was Intermediate Care Facility Mentally Retarded. Include all other non- Medicaid patients. For example, such as those who receive benefits from Medicare, VA, or private insurance. Number of patients in the nursing home who were not eligible for Medicaid when the census was taken whose level of care was Non Classified. Include all other non-medicaid patients. For example, those who receive benefits from Medicare, VA, or private insurance. Number of patients in the nursing home who were not eligible for Medicaid when the census was taken whose level of care was Hospice. Include all other non-medicaid patients. For example, those who receive benefits from Medicare, VA, or private insurance. Admits SNF ICF1 ICF2 ICF3 ICFMR Number of non-medicaid patients admitted to the nursing home during the census month whose level of care was Skilled Nursing Facility. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients admitted to the nursing home during the census month whose level of care was Intermediate Care Facility Level 1. Include Medicaid applicants, pending patients, and all other non- Medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients admitted to the nursing home during the census month whose level of care was Intermediate Care Facility Level 2. Include Medicaid applicants, pending patients, and all other non- Medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients admitted to the nursing home during the census month whose level of care was Intermediate Care Facility Level 3. Include Medicaid applicants, pending patients, and all other non- Medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients admitted to the nursing home during the census month whose level of care was Intermediate Care Facility Mentally Retarded. Include Medicaid applicants, pending patients, and all 01/19/12 125

128 other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Non Classified Hospice Number of non-medicaid patients admitted to the nursing home during the census month whose level of care was Non Classified. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients admitted to the nursing home during the census month whose level of care was Hospice. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Deaths SNF ICF1 ICF2 ICF3 ICFMR Non Classified Hospice Number of non-medicaid patients who died while in the nursing home during the census month whose level of care was Skilled Nursing Facility. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients who died while in the nursing home during the census month whose level of care was Intermediate Care Facility Level 1. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients who died while in the nursing home during the census month whose level of care was Intermediate Care Facility Level 2. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients who died while in the nursing home during the census month whose level of care was Intermediate Care Facility Level 3. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients who died while in the nursing home during the census month whose level of care was Intermediate Care Facility Mentally Retarded. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients who died while in the nursing home during the census month whose level of care was Non Classified. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients who died while in the nursing home during the census month whose level of care was Hospice. Include 01/19/12 126

129 Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Transfers SNF ICF1 ICF2 ICF3 ICFMR Non Classified Hospice Number of non-medicaid patients transferred from the nursing home during the census month whose level of care was Skilled Nursing Facility. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients transferred from the nursing home during the census month whose level of care was Intermediate Care Facility Level 1. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients transferred from the nursing home during the census month whose level of care was Intermediate Care Facility Level 2. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients transferred from the nursing home during the census month whose level of care was Intermediate Care Facility Level 3. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients transferred from the nursing home during the census month whose level of care was Intermediate Care Facility Mentally Retarded. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients transferred from the nursing home during the census month whose level of care was Non Classified. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients transferred from the nursing home during the census month whose level of care was Hospice. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Discharges SNF Number of non-medicaid patients discharged from the nursing home during the census month whose level of care was Skilled Nursing Facility. Include Medicaid applicants, pending patients, and all other non-medicaid 01/19/12 127

130 patients. For example, those who have benefits through Medicare, VA, and private insurance. ICF1 ICF2 ICF3 ICFMR Non Classified Hospice Number of non-medicaid patients discharged from the nursing home during the census month whose level of care was Intermediate Care Facility Level 1. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients discharged from the nursing home during the census month whose level of care was Intermediate Care Facility Level 2. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients discharged from the nursing home during the census month whose level of care was Intermediate Care Facility Level 3. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients discharged from the nursing home during the census month whose level of care was Intermediate Care Facility Mentally Retarded. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients discharged from the nursing home during the census month whose level of care was Non Classified. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. Number of non-medicaid patients discharged from the nursing home during the census month whose level of care was Hospice. Include Medicaid applicants, pending patients, and all other non-medicaid patients. For example, those who have benefits through Medicare, VA, and private insurance. When you have completed the form, Select Save to save the transaction. OR Select Add to save the transaction and open a new form for data entry. You can then use the Batch Submission feature to submit a number of forms at the same time. (For more information, see Sending transactions.) 01/19/12 128

131 Transaction responses When you submit an electronic transaction to Arkansas Medicaid/HP, the host system notifies you whether that transaction was accepted or rejected and supplies additional information about the transaction. PES version 2.15 generates 10 transaction responses: 271 Eligibility Response(s) Supplemental Eligibility Response Report(s) 277 Claim Status Response(s) Rejected Response Report(s) NCPDP Pharmacy Response(s) Long Term Care Census Response(s) 835 Electronic Remittance Advice(s) 278 Prior Authorization Response(s) TA1 Interchange Acknowledgement(s) 999 Acknowledgement(s) NOTE: When viewing transaction responses, PES v2.15 will only display 5010 transaction files transactions can only be viewed using PES v2.14 or earlier. 01/19/12 129

132 271 Eligibility Response(s) When you submit a 270 Eligibility Request transaction, Arkansas Medicaid returns a 271 Eligibility Response file, which lists a variety of information about the Arkansas Medicaid beneficiary. Arkansas Medicaid also returns a Supplemental Eligibility Response. Batch response You must download batch responses before you can view them. For more information about download, see Receiving files. To view a batch 271 Eligibility Response, Fields 1. From the Communication menu, select View Batch Response and 999s. A list of available files opens. 2. The first section of the window lists files that have been downloaded. The first eight characters of the file name represent the Batch Number. The last three characters of the file name represent the transaction type. After a file is viewed, the last character of the file extension is changed to V (for example, MC000025_W _357091_5010 _271.fiV). 3. Select the file you want to view. The file displays in the open window. 4. To print a copy of the response, select Print. The 271 Eligibility Response includes the following information. INFORMATION SOURCE 01/19/12 130

133 INFORMATION SOURCE SOURCE PRIMARY ID VALID REQUEST REJECT REASON FOLLOW-UP Arkansas Medicaid Displays only when 270 Eligibility Request is rejected. When displayed, value is N (No). Description of error causing 270 Eligibility Request to be rejected for information source. Description of action required from provider if 270 Eligibility Request is rejected for information source. PROVIDER INFORMATION PROVIDER LAST NAME PROVIDER FIRST NAME PROVIDER NUMBER VALID REQUEST REJECT REASON FOLLOW-UP ELIGIBILITY AUTHORIZATION # TRACE # Last name or organization name on file with Arkansas Medicaid. If Provider ID is invalid, this field does not display. First name on file with Arkansas Medicaid. If Provider ID is invalid, this field does not display. Provider ID number as it was keyed on the 270 Eligibility Request. Displays only when the 270 Eligibility Request is rejected. When displayed, value is N (No). Description of error causing 270 Eligibility Request to be rejected for provider information. Description of action required from provider if 270 Eligibility Request is rejected for provider information. Confirmation number assigned by Arkansas Medicaid if the beneficiary is eligible for services on the requested dates of service. Matches Trace # shown on Header 1 of the 270 Eligibility Request. BENEFICIARY INFORMATION BENEFICIARY LAST NAME BENEFICIARY FIRST NAME BENEFICIARY MI BENEFICIARY ID Last name on file with Arkansas Medicaid. If the last name on the 270 Eligibility Request is invalid, the invalid name displays. First name on file with Arkansas Medicaid. If the first name on the 270 Eligibility Request is invalid, the invalid name displays. Middle initial on file with Arkansas Medicaid. If the middle initial on the 270 Eligibility Request is invalid, the invalid initial displays. Beneficiary s current Arkansas Medicaid ID number. If the number on the 270 Eligibility Request is invalid, the invalid number displays. 01/19/12 131

134 BENEFICIARY ACCOUNT # BENEFICIARY DOB BENEFICIARY GENDER VALID REQUEST REJECT REASON FOLLOW-UP Patient account number assigned by you and entered on the 270 Eligibility Request. Beneficiary s date of birth. Displays only for valid 270 Eligibility Requests. Beneficiary s gender. Values: F = Female M = Male U = Unknown Displays only when the 270 Eligibility Request is rejected. When displayed, value is N (No). Description of error causing 270 Eligibility Request to be rejected for beneficiary information. Description of action required from provider if 270 Eligibility Request is rejected for beneficiary information. ELIGIBILITY INFORMATION ELIGIBILITY PLAN DESCRIPTION ELIGIBILITY BEGIN DATE ELIGIBILITY END DATE COUNTY Values: Active or inactive. Beneficiary s aid category and description of that category. First date on which the beneficiary is eligible for this aid category. Last date on which the beneficiary is eligible for this aid category. Three-digit county code followed by name of county in which beneficiary resides. TPL INSURANCE TYPE TPL POLICY # TPL GROUP # TPL MEMBER # PLAN NAME ELIGIBILITY BEGIN DATE Commercial. Identification number assigned to the policy holder by the third party insurance carrier. Group number of the third party insurance policy under which the beneficiary is covered. Identification number assigned to the policy holder by the third party insurance carrier. Third party insurance carrier s name for the plan under which the beneficiary is covered. Date on which the third party insurance policy began. 01/19/12 132

135 ELIGIBILITY END DATE TPL COVERAGE 1 TPL COVERAGE 2 TPL COVERAGE 3 TPL COMPANY CODE TPL COMPANY NAME TPL ADDRESS Date on which the third party insurance policy ended. 2-digit code for the third party insurance carrier s policy coverage and a description for that code such as, full coverage, accident policy, cancer policy, or drug only. 2-digit code for the third party insurance carrier s policy coverage and a description for that code such as, full coverage, accident policy, cancer policy, or drug only. 2-digit code for the third party insurance carrier s policy coverage and a description for that code such as, full coverage, accident policy, cancer policy, or drug only. Code assigned by Arkansas Medicaid to the third party insurance carrier. Name of the third party insurance carrier. Address of the third party insurance carrier. PRIMARY CARE PHYSICIAN BEGIN DATE END DATE MESSAGE PCP LAST NAME PCP FIRST NAME PCP SUFFIX PHONE NUMBER LOCK-IN ID Date on which the provider became the PCP for this beneficiary. Date on which the provider ceased to be PCP for this beneficiary (last day of PCP relationship). Notes whether PCP is required and, if so, whether a PCP has been assigned. If a PCP is required and assigned, the following fields are filled. Last name of the assigned PCP. First name of the assigned PCP. The provider s credential. For example, MD or RN. Telephone number of the assigned PCP. If the beneficiary is locked in to the requesting provider, the provider ID displays. If the beneficiary is locked in to a different provider, value: SOMEONE ELSE. If the beneficiary is not locked in to a provider, this field does not display. SPEND DOWN SPEND DOWN AMOUNT SPEND DOWN END DATE Amount of beneficiary s financial responsibility for medical services. If service is provided on this date, the beneficiary is responsible for charges up to the amount in the SPEND DOWN AMOUNT field. 01/19/12 133

136 IMMUNIZATIONS DATE Date of the immunization. Up to 50 immunization records can be displayed. NAME Name of immunization delivered on the date indicated. Up to 50 immunization records can be displayed. IMMUNIZATION MESSAGE Arkansas Department of Health contact information. BENEFIT LIMITS LAB/XRAY USED PRESCRIPTIONS USED OUTPATIENT VISITS USED PHYSICIAN VISITS USED INPATIENT VISITS USED CONSULTATIONS USED Dollar amount of laboratory and/or x-ray benefits used so far for this fiscal year. Number of prescriptions used so far for this fiscal year. Number of outpatient visits used so far for this fiscal year. Number of physician visits used so far for this fiscal year. Number of inpatient visits used so far for this fiscal year. Number of consultations used so far for this fiscal year. VISION DATE LAST VISION EXAM OPTICAL SCRIPT DATE CHIROPRACTIC VISITS WAIVER ELIGIBILTIY ADULT DENTAL CARE ORTHODONTICS Date of most recent eye examination on the beneficiary s Arkansas Medicaid record. Date of the most recent eyeglass or contact lens prescription on the beneficiary s Arkansas Medicaid record. Number of chiropractic visits used so far for this state fiscal year. Begin and end dates of waiver eligibility segment. Dollar amount used so far for this state fiscal year. Date of orthodontic treatment. LTC LIABILITY AMOUNT Beneficiary s liability (resource) amount. 01/19/12 134

137 LIABILITY BEGIN DATE LIABILITY END DATE LTC BEGIN DATE LTC END DATE LOC BEGIN DATE LOC END DATE LEVEL OF CARE Beneficiary s liability amount is applicable beginning on this date. Beneficiary s liability amount is applicable through this date. Start date of beneficiary s eligibility for long term care services. Ending date of the beneficiary s eligibility for long term care services. Start date of the beneficiary s level of care (LOC). The beneficiary can have an LOC of 20 (Skilled Nursing Facility) and change to an LOC of 22 (Intermediate Care Facility Type 1). Ending date of the beneficiary s level of care (LOC). The beneficiary can have an LOC of 20 (Skilled Nursing Facility) and change to an LOC of 22 (Intermediate Care Facility Type 1). Code for and description of the type of facility at which the beneficiary resides. MEDICARE BUYIN BUY-IN HIC NUMBER Indicates whether beneficiary has Medicare Part A, Part B, or both. Health insurance claim number assigned by Medicare. WAIVER TYPE AMOUNT BEGIN DATE END DATE Code for and description of the waiver services. Total dollar amount applied to waiver services. First date on which the waiver is effective. Last date on which the waiver is effective. 01/19/12 135

138 277 Claim Status Response(s) When you submit a 276 Claim Status Request transaction,arkansas Medicaid returns a 277 Claim Status Response file. For each claim in the batch that was accepted for processing, the Claim Status Response lists an ICN. Each claim that was denied is also listed, and a Rejected Response Report is generated for each denied claim. See Rejected Response Report for details about why the claims were denied. The 277 Claim Status Response includes the following information. BATCH # RECEIVED DATE Number assigned automatically to this batch of claims. Date on which the transaction was received by the Arkansas Medicaid system. INFORMATION SOURCE PAYER NAME Arkansas Medicaid PAYER ID RECEIVING PROVIDER INFORMATION 01/19/12 136

139 LAST/ORG NAME FIRST NAME BATCH SUBMITTER ID If the provider to be paid is an organization, the organization s name. If the provider to be paid is an individual, the last name of that individual. If the provider to be paid is an individual, the first name of that individual. The submitter ID ( MC number ) of the provider to be paid. SERVICE PROVIDER INFORMATION PROVIDER LAST/ORG NAME PROVIDER FIRST NAME PROVIDER ID If the provider that performed the service is an organization, the organization s name. If the provider that performed the service is an individual, the last name of that individual. If the provider that performed the service is an individual, the first name of that individual. NPI or Arkansas Medicaid Provider ID of the provider that performed the service. BENEFICIARY INFORMATION BENEFICIARY DOB BENEFICIARY GENDER BENEFICIARY LAST NAME BENEFICIARY FIRST NAME BENEFICIARY MI BENEFICIARY ID Beneficiary s date of birth. Beneficiary s gender. Values: F = Female M = Male U = Unknown Beneficiary s last name. Beneficiary s first name. Beneficiary s middle initial. Beneficiary s Arkansas Medicaid ID number. CLAIM LEVEL STATUS INFORMATION REQUEST TRACE # CLAIM STATUS CATEGORY CLAIM STATUS PROCESSED DATE System generated. National code signifying the status of the claim, such as accepted, rejected, or additional information requested. National code further defining the claim status category. Date on which the claim was processed. 01/19/12 137

140 TOTAL BILLED AMOUNT ICN FROM/TO DATE OF SERVICE Total amount of the claim. ICN assigned to the claim. From date and to date of service for the claim. 01/19/12 138

141 278 Prior Authorization Response(s) When you request prior authorization for treatment (278 Prior Authorization Request), Arkansas Medicaid returns a 278 Prior Authorization Response file. The response confirms that your request was accepted and provides the prior authorization number to be used in submitting claims for the service. If your request was rejected, the response guides you in correcting the problem so you can resubmit the request. The 278 Prior Authorization Response includes the following information. UMO NAME UMO IDENTIFIER UMO CONTACT NAME Arkansas Medicaid Code for department reviewing this PA. Name of department reviewing this PA. REQUESTING PROVIDER PROVIDER LAST Last name of the provider requesting the PA. 01/19/12 139

142 NAME PROVIDER FIRST NAME BATCH SUBMITTER ID PROVIDER ID First name of the provider requesting the PA. Submitter ID ( MC number ) of the provider requesting the PA. NPI or Arkansas Medicaid Provider ID number of the provider requesting the PA. BENEFICIARY TRACE INFORMATION RESPONSE TRACE # REQUEST TRACE # Unique ID number for this response. Assigned by system. Unique ID number for this request. Assigned by system. BENEFICIARY DIAGNOSIS INFORMATION DIAGNOSIS CODE 1 Diagnosis code for which the PA was requested. BENEFICIARY INFORMATION BENEFICIARY LAST NAME BENEFICIARY FIRST NAME BENEFICIARY ID BENEFICIARY ACCOUNT # Last name of the beneficiary for whom the PA was requested. First name of the beneficiary for whom the PA was requested. Arkansas Medicaid ID number of the beneficiary for whom the PA was requested. Patient account number assigned by the provider requesting the PA. SERVICE PROVIDER PROVIDER LAST/ORG NAME PROVIDER FIRST NAME PROVIDER ID If the provider performing the service is an organization, the organization name. If the provider performing the service is an individual, the provider s last name. If the provider performing the service is an individual, the provider s first name. NPI or Arkansas Medicaid Provider ID number of the provider performing the service. SERVICE LEVEL REQUEST TYPE Type of PA requested. Values: I = Initial R = Revision 01/19/12 140

143 A = Appeal DECISION PA NUMBER ISSUE DATE PA ISSUE DATE PROCEDURE CODE FDOS TDOS UNITS TOOTH NUMBERS Outcome of PA review. Values: Approved Denied Pending Prior authorization number to be used on claims for this service. Issue date of current PA. Issue date of original PA, if any. Procedure code to which the PA applies. From date and to date of service to which the PA applies. Number of units of service authorized. If applicable, tooth numbers for which service is authorized. 01/19/12 141

144 835 Electronic Remittance Advice If you have signed up to receive electronic remittance advices, you can retrieve an electronic copy of your RA each Monday. If you want to sign up to receive electronic RAs, call the EDI Help Desk at (501) for local and out-of-state providers or toll free at (800) for in-state providers. The 835 Electronic Remittance Advice includes the information outlined in the table below. These fields are repeated for each claim included in the RA. Only fields that have live data are shown on the RA. If a field is blank, its label is also omitted from the RA. BILLING PROVIDER INFORMATION NAME SSN/EIN ADDRESS 1 ADDRESS 2 Payee s name. Payee s Social Security number or Employer Identification Number. First line of payee s address. Second line of payee s address. 01/19/12 142

145 CITY STATE ZIP ID Payee s city. Payee s state. Payee s zip code. Payee s NPI or Arkansas Medicaid Provider ID number. PAYER INFORMATION NAME ADDRESS 1 ARKANSAS MEDICAID 500 PRESIDENT CLINTON AVE ADDRESS 2 SUITE 400 CITY STATE LITTLE ROCK AR ZIP FINANCIAL INFORMATION PAID AMOUNT EFT INDICATOR Total amount paid to provider. Indicates whether payment was by Electronic Funds Transfer. PAYER DFI ID PAYER BANK ACCOUNT # PAYER ID PROVIDER DFI ID PROVIDER ACCOUNT # RA DATE/EFT DATE INTERNAL CHECK/EFT# RECEIVER ID PRODUCTION DATE Payee s Depository Financial Institution ID. Payee s bank account number. Date on which check was issued or EFT was effective. Trace number for check or EFT transaction. Submitter ID ( MC number ) of payee. Date on which RA was produced. CLAIM PAYMENT INFORMATION PATIENT ACCOUNT # Patient account number assigned by the provider submitting the claim. 01/19/12 143

146 CLAIM STATUS BILLED AMOUNT PAID AMOUNT CO-PAY ICN POS CLAIM FREQUENCY CODE BENEFICIARY LAST NAME BENEFICIARY FIRST NAME BENEFICIARY MIDDLE BENEFICIARY MEDICAID ID ATTENDING PROVIDER LAST/ORG NAME PROVIDER FIRST NAME PROVIDER ID ORIGINAL ICN PRIOR AUTHORIZATION # MEDICAL RECORD # FROM DATE OF SERVICE TO DATE OF SERVICE National code signifying the status of the claim, such as accepted, rejected, or additional information requested. Total amount billed for this claim. Total amount paid for this claim. Total amount for which the beneficiary is responsible. Claim number. Place-of-service code. Indicates whether this is an original claim or a transaction voiding or adjusting a previous claim. Values: 1 = Original claim 7 = Adjustment 8 = Void Beneficiary s last name. Beneficiary s first name. Beneficiary s middle initial. Beneficiary s Arkansas Medicaid ID number. The attending provider s last name. The attending provider s first name. Attending provider s NPI or Arkansas Medicaid Provider ID. If this transaction voids a previous claim, the ICN of the original claim. Prior authorization number assigned to this claim. Medical record number assigned by the provider submitting the claim. Date on which service began for this claim. Date on which service ended for this claim. 01/19/12 144

147 ALLOWED AMOUNT Maximum amount paid by Arkansas Medicaid for this service. DETAIL PAYMENT INFORMATION These fields are repeated for each detail included in the claim. DETAIL [NUMBER] PAID PROC/REV/NDC MODIFIER DETAIL BILLED AMOUNT DETAIL PAID AMOUNT REVENUE CODE PAID UNITS SUBMITTED PROC/REV/NDC MODIFIER SUBMITTED UNITS DATE OF SERVICE ADJUSTMENT REASON ADJUSTMENT AMOUNT PERFORMING PROVIDER ID DETAIL ALLOWED AMOUNT REMITTANCE ADVICE CODE Procedure code for which this detail was paid. Procedure modifier for this detail. This field can be repeated up to four times. Amount billed for this line item. Amount paid for this line item. National Uniform Billing Committee (NUBC) revenue code for this line item. Number of units paid for this line item. Procedure code that was submitted for this detail. Procedure modifier that was submitted for this detail. This field can be repeated up to four times. Number of units submitted for this line item. Date of service for this detail. Claim adjustment reason code and description. Amount of adjustment to this detail. Performing provider s NPI or Arkansas Medicaid Provider ID number. Maximum amount paid by Arkansas Medicaid for this detail. Code and description for remarks related to this detail. SUMMARY OF PROVIDER ADJUSTMENTS 01/19/12 145

148 BILLING PROVIDER ID FISCAL YEAR- END Billing provider s NPI or Arkansas Medicaid Provider ID number. Date on which fiscal year ends. The following three fields can be repeated up to five times: ADJUSTMENT REASON ADJUSTMENT IDENTIFIER ADJUSTMENT AMOUNT Code representing the reason an adjustment was necessary. Control number for this adjustment. Amount of adjustment. 01/19/12 146

149 999 Acknowledgement(s) When you submit a transaction, but something other than the data is invalid (for example the claim format), the system generates a 999 Acknowledgement. To resolve the issue, print the 999 Acknowledgement and then call the EDI Help Desk at (501) for local and out-of-state providers or toll free at (800) for in-state providers. 01/19/12 147

150 Rejected Response Report If you submit one or more claims in a batch and at least one of the claims is denied, the system generates a Rejected Response Report for that batch. This report explains the reasons each claim was rejected. You can use the information from this report to correct your claim in order to resubmit it. The Rejected Response Report includes the following information. BATCH ID PROVIDER ID BENEFICIARY ID PATIENT ACCOUNT # FROM DATE OF SERVICE TOTAL BILL AMOUNT NUMBER OF ERRORS Number assigned automatically to this batch of claims. NPI or Arkansas Medicaid ID of the provider submitting the claim. Beneficiary s Arkansas Medicaid ID number. Patient account number assigned by the provider submitting the claim. From date of service for the claim. Total amount of the claim. Count of the errors encountered in the claim. The body of the report lists each element of a claim that contains an error, the 4-digit code that 01/19/12 148

151 applies to that error, and a brief description of the error. For example, HEADER 1071 PRIMARY CARE PHYSICIAN REQUIRED / NONE ASSIGNED 01/19/12 149

152 NCPDP Pharmacy Response(s) When you submit an NCPDP Pharmacy transaction, Arkansas Medicaid returns an NCPDP Pharmacy Response file, which explains the disposition of the claim. The NCPDP Pharmacy Response file includes the following information. VERSION/ RELEASE NUMBER TRANSACTION CODE HEADER RESPONSE STATUS RESPONSE DATE PROVIDER ID D.0 B1 Billing Indicates whether the claim was accepted or rejected. Date and time at which the response was generated. NPI or Arkansas Medicaid Provider ID of the provider submitting the 01/19/12 150

153 claim. DATE OF SERVICE Date on which the service was performed. The following fields are repeated for each detail included in the claim. CLAIM DETAIL TRANSACTION STATUS Number of the claim detail. Status of the transaction. Values: P = Paid R = Rejected If the detail is paid, the next two fields are ICN and APPROVAL CODE COUNT. If the detail is rejected, the next two fields are REJECT COUNT and REJECT CODE. ICN APPROVAL CODE COUNT REJECT COUNT REJECT CODE ADDITIONAL INFORMATION HELP DESK PHONE PRESCRIPTION # ICN assigned to the claim. Number of details paid. Number of rejection codes generated by this claim Rejection codes generated by this claim with brief descriptions. Notations that further explain the action taken regarding this claim. (800) Prescription number associated with this claim. 01/19/12 151

154 TA1 Interchange Acknowledgement(s) A TA1 response is a variation of an error report for a failed transaction. If your response includes the characters TA1 within the transaction dump area, print the response and then call the EDI Help Desk at (501) for local and out-of-state providers or toll free at (800) for in-state providers. 01/19/12 152

155 Long Term Care Census Response(s) Before you can file Long Term Care claims, you must have an accepted census for the previous month. Further, the amount Arkansas Medicaid pays in some cases is related to the facility s occupancy rate. When you submit a Long Term Care Census transaction, Arkansas Medicaid returns a Long Term Care Census Response file, which confirms that your census has been accepted and shows the occupancy rate; or if it is rejected, it includes information that helps you correct and resubmit your census. The Long Term Care Census Response file includes the following information. TRANSACTION TYPE LTC CENSUS Date on which census response was produced. Time at which census response was produced. PAY TO PROVIDER NUMBER OCCUPANCY PERCENTAGE CENSUS DATE NPI or Arkansas Medicaid Provider ID number of the entity or individual that receives payment against this census. Number of beds occupied in facility divided by number of beds available. Month and year to which the census applies. All remaining fields in the response file are identical to those in the Long Term Care Census form. Supplemental Eligibility Response Report(s) When you submit a 270 Eligibility Request transaction, Arkansas Medicaid returns two files: a 271 Eligibility Response file and a Supplemental Eligibility Response Report. The supplemental report delivers additional information about the transaction that cannot be included on the 271 Eligibility Response due to HIPAA formatting constraints. 04/19/12 153

156 NOTE: The Supplemental Eligibility Response Report is generated in response only to 270 Eligibility Requests that are submitted in batches or through the Arkansas Medicaid website. An accepted Supplemental Eligibility Response Report includes the following information. Only fields that have live data are shown on the report. If a field is blank, its label is omitted from the report, too. BATCH ID PROVIDER ID BENEFICIARY ID PATIENT ACCOUNT # FROM DATE OF SERVICE BENEFICIARY NAME ERROR COUNT ELIGIBILITY SEGMENT COUNT BENEFICIARY ID AID CATEGORY AID CATEGORY DESCRIPTION Number assigned automatically to this batch of transactions. NPI or Arkansas Medicaid Provider ID. Beneficiary s Arkansas Medicaid ID number. Patient account number assigned by the provider submitting the eligibility request. Beginning date of service. Beneficiary s name. Count of the errors encountered in the transaction. 0 = No errors; transaction accepted Number of eligibility segments listed for this beneficiary. Determined by the number of Beneficiary ID numbers on record for this beneficiary. Maximum: 4. Beneficiary s Arkansas Medicaid ID number. Aid category determining the benefits this beneficiary receives. Description of aid category. 04/19/12 154

157 ELIGIBILITY BEGIN DATE ELIGIBILITY END DATE COUNTY CODE COUNTY TPL SEGMENT COUNT TPL COMPANY CODE TPL SUBSCRIBER NAME Date on which beneficiary s eligibility for services begins. Date on which beneficiary s eligibility for services ends. 2-digit code for beneficiary s county of residence. Beneficiary s county of residence. Number of TPL segments included in this report. Maximum: 3. Each segment has the following 2 fields: National Electronic Insurance Clearinghouse (NEIC) code identifying the insurance carrier. Name of the insured for the above carrier. BUYIN PART A PART B Date on which this beneficiary became eligible for Medicare Part A benefits. Date on which this beneficiary became eligible for Medicaid Part B benefits. ARKIDS A EPSDT SCREENINGS DENTAL MEDICAL HEARING VISION Date of beneficiary s last EPSDT dental screening. Date of beneficiary s last EPSDT medical screening. Date of beneficiary s last EPSDT hearing screening. Date of beneficiary s last EPSDT vision screening. ARKIDS B SCREENINGS DENTAL MEDICAL HEARING VISION Date of beneficiary s last ARKids B dental screening. Date of beneficiary s last ARKids B medical screening. Date of beneficiary s last ARKids B hearing screening. Date of beneficiary s last ARKids B vision screening. DENTAL PANORAMIC / FULL MOUTH XRAY Date of beneficiary s last panoramic/full mouth x-ray. 04/19/12 155

158 BITEWINGS PROPHYLAXIS / FLOURIDE SEALANT TOOTH 2 SEALANT TOOTH 3 SEALANT TOOTH 14 SEALANT TOOTH 15 SEALANT TOOTH 18 SEALANT TOOTH 19 SEALANT TOOTH 30 Date of beneficiary s last bitewing x-rays. Date of beneficiary s last prophylaxis/fluoride treatment. Date sealant was applied to beneficiary's tooth 2. Date sealant was applied to beneficiary's tooth 3. Date sealant was applied to beneficiary's tooth 14. Date sealant was applied to beneficiary's tooth 15. Date sealant was applied to beneficiary's tooth 18. Date sealant was applied to beneficiary's tooth 19. Date sealant was applied to beneficiary's tooth 30. A rejected Supplemental Eligibility Response Report includes the following information. BATCH ID PROVIDER ID BENEFICIARY ID PATIENT ACCOUNT # FROM DATE OF SERVICE BENEFICIARY NAME ERROR COUNT Number assigned automatically to this batch of transactions. NPI or Arkansas Medicaid Provider ID. Beneficiary s Arkansas Medicaid ID number. Patient account number assigned by the provider submitting the eligibility request. Beginning date of service. Beneficiary s name. Count of the errors encountered in the transaction. The body of the report lists all applicable error codes along with brief descriptions of the errors. For example, ERROR CODE 1: Y350 MEDICARE ALLOWED AMOUNT MUST BE NUMERIC AND GREATER THAN ZERO 04/19/12 156

159 Communication Use the Communication menu to interact with Arkansas Medicaid via its fiscal agent, HP. Through this menu you can submit transactions, retrieve responses, and view communication logs. The following commands are available on the Communication menu: Submission Resubmission View Batch Response and 999s View Batch LTC Census Response View Rejected Response Report View Supplemental Eligibility Response View Batch 835 ERA Response View Communication Log 01/19/12 157

160

161 Submission Use the Submission command on the Communication menu to send a batch of Arkansas Medicaid transactions to HP electronically. A batch consists of one or more requests or claims. NOTE: You must set up PES options before you can submit transactions. If you have not yet done so, see Options. The following instructions describe how to send transactions and receive files separately; however, you can send files and receive transactions in the same submissions session. Sending transactions When you have one or more transactions with R (Ready to transmit) status, you can send a batch: 1. From the Communication menu, select Submission. The Batch Submission window opens. 2. In the Files To Send box, select each type of transaction you want to send. Or select Select All to send all transactions types with R status. 3. Select Submit. Submitting via internet, PES transmits all transactions with R status. Once submitted, a message is returned stating Submission successful! 4. If the transmission fails, you can view the Communication Log files to learn why. 5. Web Server is the submission method default on the initial installation or upgrade of v /19/12 159

162 Receiving files To receive files: 1. From the Communication menu, select Submission. The Batch Submission window opens. 2. In the Files To Receive box, select each type of file you want to retrieve. Or select Select All to receive all files that are waiting to be downloaded. 3. Select Submit. Submitting via internet, PES retrieves all waiting response files. Once submitted, a message is returned stating Submission successful! 4. If the transmission fails, you can view the Communication Log files to learn why. 01/19/12 160

163 Web Submission Password Change/Reminder To change your web submission password: 1. When activating a submission (sending or receiving), the Password Expiration Reminder window will open beginning 60 days after updating the password. 2. The web submission password expires after 90 days so it is recommended to reset the password prior to day If the user clicks on the No button, the user will be allowed to continue the submission process, 4. If the user clicks on the Yes button, the Reset Password window opens. 5. Enter the existing password in the Old Password field. Enter the new password in the New Password field and re-enter the new password in ReKey New Password field to confirm. Click the OK button. 6. Requirements for creating a secure password are: Contain minimum 8 characters and maximum of 32 characters Contain at least 1 uppercase alpha-character Contain at least 1 lowercase alpha-character Contain at least 1 number Contain at least 1 special character (such as $ or!) Cannot be the same as the user identifier (MC ID) Cannot contain the same character more than twice Cannot contain a detectable pattern such as a dictionary word (with the use of the other type characters, this shouldn t be an issue) Must differ from your previous 6 passwords 7. If the password is successfully accepted, the window below will open to inform you that your new password will expire in 90 days. 01/19/12 161

164 8. The window below will open when activating a submission on day 90 which is the last day you can reset your password prior to expiration. 9. The window below will appear when your password has expired. 01/19/12 162

165 Resubmission Depending on the system options you have selected (see Options), as many as 999 batches of forms can be retained on your computer. Of these, you can resend a single form, several forms, or an entire batch of forms. Use the Resubmission command on the Communication menu to resubmit forms when transmission was interrupted and the transaction did not complete. To resubmit forms: 1. From the Communication menu, select Resubmission. A list of batches stored on your computer opens. 2. Select the batch that includes the forms you want to resubmit. A list of forms within that batch opens. By default, all of the forms already are selected. 3. To resubmit the entire batch, select Resubmit. OR To resubmit only some of the forms in the batch, select Deselect All, and then select each form you want to resubmit. 4. Select Resubmit. The Batch Submission screen opens, and you can proceed as if sending a regular batch. 01/19/12 163

166 View Batch Response and 999s Batch responses and 999 acknowledgements list details about claims that were accepted or rejected by Arkansas Medicaid. If a claim is rejected, the file includes a list of errors that prevented the transaction from being accepted. After you retrieve these files, use View Batch Response and 999s to view them. 1. From the Communication menu, select View Batch Response and 999s. A list of available files opens. 2. Select the file you want to view. The file displays in the open window. 3. If you want to print the file, select Print. The first section of the window lists files that have been downloaded. Click the file name to open the file. The last three characters of the file name represent the transaction type. After a file is viewed, the last character of the file extension is changed to V (for example, MC900025_W _ FIV). 01/19/12 164

167 View Batch LTC Census Response The LTC Census Report verifies the Long Term Care facility s occupancy rate and summarizes census data reported to Arkansas Medicaid. After you retrieve these files, use View Batch LTC Census Response to view them. 1. From the Communication menu, select View Batch LTC Census Response. A list of available files opens. 2. Select the file you want to view. The file displays in the open window. 3. If you want to print the file, select Print. The first section of the window lists files that have been downloaded. Click the file name to open the file. The last three characters of the file name represent the transaction type. After a file is viewed, the last character of the file extension is changed to V (for example, MC900025_W _ CEN.FIV). 01/19/12 165

168 View Rejected Response Report The Rejected Response Report displays details about claims that have been rejected by Arkansas Medicaid. The report lists the number of errors, the locations of the errors, and the error codes and descriptions. Use this report to identify claim errors so you can correct them and resubmit the claims. After you retrieve these files, use View Rejected Response Report to view them. 1. From the Communication menu, select View Rejected Response Report. A list of available files opens. 2. Select the file you want to view. The file displays in the open window. 3. If you want to print the file, select Print. The first section of the window lists files that have been downloaded. Click the file name to open the file. The last three characters of the file name represent the transaction type. After a file is viewed, the last character of the file extension is changed to V (for example, MC900025_W _ REJ.FIV). 01/19/12 166

169 View Supplemental Eligibility Response When you submit a 270 Eligibility Request transaction, Arkansas Medicaid returns two files: a 271 Eligibility Response file and a Supplemental Eligibility Response Report. The supplemental report delivers additional information about the transaction that cannot be included on the 271 Eligibility Response due to HIPAA formatting constraints. NOTE: The Supplemental Eligibility Response Report is generated in response only to 270 Eligibility Requests that are submitted in batches or through the Arkansas Medicaid website. After you retrieve these files, use View Supplemental Eligibility Response to view them. 1. From the Communication menu, select View Supplemental Eligibility Response. A list of available files opens. 2. Select the file you want to view. The file displays in the open window. 3. If you want to print the file, select Print. The first section of the window lists files that have been downloaded. Click the file name to open the file. The last three characters of the file name represent the transaction type. After a file is viewed, the last character of the file extension is changed to V (for example, MC900025_W _ ELG.FIV). 04/19/12 167

170 View Batch 835 ERA Response If you have signed up to receive electronic remittance advices, you can retrieve an electronic copy of your RA each Monday. If you want to sign up to receive electronic RAs, call the EDI Help Desk at (501) for local and out-of-state providers or toll free at (800) for in-state providers. Use the RA to support your internal accounting procedures. After you retrieve the file, use View Batch 835 ERA Response to view it. 1. From the Communication menu, select View Batch 835 ERA Response. A list of available files opens. 2. Select the file you want to view. The file displays in the open window. 3. If you want to print the file, select Print. The first section of the window lists files that have been downloaded. Click the file name to open the file. The last three characters of the file name represent the transaction type. After a file is viewed, the last character of the file extension is changed to V (for example, MC900025_WEEKLY_ _0_ FIV). 01/19/12 168

171 View Communication Log Use the Communication Log to check submission information. It lists files submitted along with file size, creation date, and creation time. Depending on the system options you have selected (see Options), as many as 999 communication logs can be saved on your computer. 1. From the Communication menu, select View Communication Log. The Communication Log window opens, displaying a list of recent submissions. 2. Select the log you want to view. 3. If you want to print the log, select Print. 01/19/12 169

172 Lists PES uses lists to simplify data entry and help ensure accuracy. Some lists are preloaded; others you must build. Once you have entered data in a list, you can reuse it from any form that includes that field. For example, as you create and add to your list of Beneficiary IDs, that data becomes available from any form that has a Beneficiary ID field. You can build a list in advance, and you can build and add to lists as you enter data into forms. NOTE: If you reload PES, you will lose your data. Do not use the full version to load PES Use only the upgrade to avoid losing your data. 01/19/12 170

173 Building a list in advance To speed claim submission later, build lists of your most frequently used data in advance. The lists you must build depend on the types of services you render. Building a list as you enter data You can add entries to most lists as needed while you are filling out a form. To add an entry, 1. Double-click in the field containing the list. A data-entry window opens. 2. Fill in the information required by the list. 3. Select Save. The entry is added to the list. 4. Choose Select. The data you just entered is inserted on the form you are filling out. Preloaded lists The following lists are preloaded on PES: Attachment Type Place of Service You may edit these lists and delete codes you know are not used in your practice. A shorter list is easier to use when completing forms. Lists to build To open any of the following lists for data entry, select the list from the Lists menu. 01/19/12 171

174 Billing/Requesting Provider Provider ID Provider s NPI or Arkansas Medicaid Provider ID. If the provider is eligible for an NPI, the NPI must be used here. If the provider is not eligible for an NPI, the provider s Arkansas Medicaid provider identification number is used, and SSN/EIN is required. ID Type Entity Type Last/Org Name First Name Tax ID Type SSN/EIN Taxonomy Values: Medicaid NPI Values: 1 Person (the provider is an individual) 2 Non-Person (the provider is a group, organization, or facility) If Entity Type is 1 (Person), provider s last name. If Entity Type is 2 (Non- Person), name of the group, organization, or facility. If Entity Type is 1 (Person), provider s first name. If Entity Type is 2 (Non- Person), this field is unavailable. Values: EIN SSN Provider s Social Security Number or Employer Identification Number. Provider s Taxonomy code, used when needed to identify a provider. Optional. 01/19/12 172

175 Provider Address Address City State Zip Provider s street address. DO NOT enter a P.O. box number here. Provider s city. 2-character postal abbreviation for state. First 5 digits of zip code are required. Space is available for +4 digits. Last 4 digits are used when needed to identify a provider. 01/19/12 173

176 Beneficiary/Patient/Cardholder/Client Beneficiary ID Account # Beneficiary SSN Last Name First Name Beneficiary DOB Gender Beneficiary s 10-digit Arkansas Medicaid ID number. Unique patient ID assigned by your facility. Beneficiary s Social Security Number. Optional. Beneficiary s last name. Beneficiary s first name. Beneficiary s date of birth. Format: MM/DD/YYYY. Values: F Female M Male U Unknown Address Address City State Zip Beneficiary s street or mailing address. Beneficiary s city. 2-character postal abbreviation for state. First 5 digits of zip code are required. Space is available for +4 digits. 01/19/12 174

177 Attending/Operating Provider NPI Last Name First Name Attending Taxonomy Provider s National Provider Identifier. Provider s last name. Provider s first name. Provider s Taxonomy code used when needed to identify a provider. Optional. 01/19/12 175

178 Facility/Performing/Referring/Service Provider Provider ID Provider s NPI or Arkansas Medicaid Provider ID. If the provider is eligible for an NPI, the NPI must be used here. If the provider is not eligible for an NPI, the provider s Arkansas Medicaid provider identification number is used, and SSN/EIN is required. ID Type Entity Type Last/Org Name First Name Taxonomy Facility License # Address City State Values: NPI, Medicaid Values: 1 Person (the provider is an individual) 2 Non-Person (the provider is a group, organization, or facility) If Entity Type is 1 (Person), provider s last name. If Entity Type is 2 (Non- Person), name of the group, organization, or facility. If Entity Type is 1 (Person), provider s first name. If Entity Type is 2 (Non- Person), this field is unavailable. Provider s Taxonomy code, used when needed to identify a provider. Optional. Required for Hospice Long Term Care claims. License # of the facility where the beneficiary resides. Provider s street address. Provider s city. 2-character postal abbreviation for provider s state. Zip First 5 digits of provider s zip code are required. Space is available for +4 digits. 01/19/12 176

179 Tax ID Type SSN/EIN Values: EIN, SSN Provider s Social Security Number or Employer Identification Number. 01/19/12 177

180 NCPDP Billing/Prescribing/NET Destination Provider Provider ID ID Type Last/Org Name First Name Provider s NPI. Type of provider identification number. Select NPI = National Provider Identifier If the provider is an organization, the organization s name. If the provider is an individual, the last name of that individual. Provider s first name. Provider Address Address City State Provider s street address. Provider s city. 2-character postal abbreviation for provider s state. Zip First 5 digits of provider s zip code are required. Space is available for +4 digits. 01/19/12 178

181 Facility Name and Address Facility Name NPI Address 1 Address 2 City State Zip Name of facility where services were rendered. Provider s NPI. Required if service was performed at an RSPMI satellite facility. Street address of facility where services were rendered. Second street address line, if needed. City where services were rendered. 2-character postal abbreviation for state. First 5 digits of zip code are required. Space is available for +4 digits. 01/19/12 179

182 Admit Source Admit Source Code Description National code indicating the source of the admission. (See National Uniform Billing Committee codes.) Definition of the code. 01/19/12 180

183 Attachment Type Code Attachment Type Code Description Code for the title or contents of a document, report, or supporting item for this claim. Definition of the code. 01/19/12 181

184 Carrier Carrier Code Code identifying the insurance carrier the third party liability (TPL) carrier codes assigned by the Arkansas Medicaid Program. The only code that is pre-loaded is XXX Unknown Carrier Code. Users must load valid carrier codes from the most current list found at Carrier Name Name of the associated insurance carrier. 01/19/12 182

185 Condition Code Condition Code Description Code for condition related to this bill that may affect payer processing. (See National Uniform Billing Committee codes.) Definition of the code. 01/19/12 183

186 Diagnosis Diagnosis Code Description Code for the condition or disease being treated. (See International Classification of Diseases coding manual). Definition of the code. 01/19/12 184

187 Modifier Modifier Code Description Code that can be appended to the end of a procedure code, altering the service without changing the procedure code. Definition of the code. 01/19/12 185

188 Occurrence Occurrence Code Description Code defining a significant event relating to this claim. See the National Uniform Billing committee (NUBC) manual. Definition of the code. 01/19/12 186

189 Patient Status Patient Status Description Code for the beneficiary s status on the last day being billed. See the National Uniform Billing Element Specifications for a list of codes. Definition of the code. 01/19/12 187

190 Place of Service Place of Service Code Description Code for the location at which the service was delivered. Definition of the code. 01/19/12 188

191 Policy Holder Beneficiary ID Carrier Code Carrier Name Group # Beneficiary s 10-digit Arkansas Medicaid ID number. Code identifying the insurance carrier the third party liability (TPL) carrier code assigned by the Arkansas Medicaid Program. Select the code from the list. If the code is not in the list, double-click in the Carrier Code field. A data-entry screen opens. Enter a valid carrier code from the most current list found at Select Save, and then choose Select. Name of the associated insurance carrier. Insurance group number. If a group number is not applicable, type the beneficiary s policy number. For Medicare beneficiaries, type the beneficiary s HIC number. Group Name Group name associated with Group #. Policy Holder Information Last Name First Name Member/ Policy # Date Of Birth Last name of insurance policy holder. First name of insurance policy holder. Identification number assigned to the policy holder by the insurance carrier. Policy holder s date of birth. Format: MM/DD/YYYY. 01/19/12 189

192 Gender Values: F Female M Male U Unknown Policy Holder Address Information Address City State Zip Policy holder s street address. Policy holder s city. Two-character postal abbreviation for state. First 5 digits of zip code are required. Space is available for +4 digits. Patient Information Insurance Type Code Relationship to Insured Select a code from the list. Select a code from the list. 01/19/12 190

193 Procedure/NDC Procedure/NDC Description Identification code for the service provided or product dispensed. Definition of the code. 01/19/12 191

194 Revenue Revenue Code Description Code for the charge for an inpatient or outpatient facility or ancillary service. Code list is available from the National Uniform Billing Committee. Definition of the code. 01/19/12 192

195 Type of Bill Type Of Bill Description Code identifying the place of service or the type of bill related to the location at which a health care service was rendered. The first and second positions are the place of service, and the third position is the claim frequency. Definition of the code. 01/19/12 193

196 Value Code Value Code Description Code for the whole unit, days or monetary nature of the amount expressed in the value amount field. Definition of the code. 01/19/12 194

197 Reports Use the Reports menu to view or print records of transactions you submit, files you retrieve, and lists you have created. Detail Forms reports show all fields for a particular form. Summary Forms reports list groups of forms in tabular format. List reports show all entries in a list in tabular format. Detail Forms reports Detail reports are available for all forms. To generate a detail report: 1. From the Reports menu, select Detail Forms, and then select the form for which you want a report. The Detail Report window opens, displaying the data entered on the claim or request. 2. If you want to narrow the report, enter data into one of the following fields. If you do not narrow the report, all forms on the database for that form type are included in the report. 01/19/12 195

198 Beneficiary ID Submit Date Form Status Beneficiary s 10-digit Arkansas Medicaid ID number. Date on which the batch of forms was submitted. Select one from the list. 3. Select OK. PES generates the report and opens it. 4. If you want a paper copy of the report, select Print. 01/19/12 196

199 Summary Forms reports Summary reports are available for all forms. To generate a summary report: 1. From the Reports menu, select Summary Forms, and then select the form for which you want a report. The Summary Report window opens, displaying a summary of data entered. 2. If you want to narrow the report, enter data into one of the following fields. If you do not narrow the report, all forms on the database for that form type are included in the report. 01/19/12 197

200 Beneficiary ID Submit Date Form Status Beneficiary s 10-digit Arkansas Medicaid ID number. Date on which the batch of forms was submitted. Select one from the list. 3. Select OK. PES generates the report and opens it. 4. If you want a paper copy of the report, select Print. 01/19/12 198

201 List reports Reports are available for the following lists: Admit Source Admission Type Attachment Type Code Carrier Condition Code Diagnosis Modifier Occurrence Patient Status Place of Service Policy Holder Procedure/NDC Revenue Type of Bill Value Code To generate a list report: From the Reports menu, select the name of the list for which you want a report. The Master Listing window opens to a preview of the report. If you want a paper copy of the report, select Print. 01/19/12 199

202 Tools The Tools menu includes the following commands: Archive base Recovery Change Password Options 01/19/12 200

203 Archive Use the Archive tool to store older forms in a compressed format. Archiving reduces the size of the database, so PES works faster while keeping older forms on hand in case you need to refer to them. PES notifies you when it is time to archive forms, based on the setting you establish in the Retention option. (See Options.) The default setting is 30 days. For example, if you accept the default Retention setting for Archive Days, PES reminds you to archive at 30-day intervals. When you create an archive, PES copies any form you submitted more than 30 days ago to a compressed file, and then it deletes that form from the database. You can copy archives to disks or CDs to maintain historical files offline. Forms that are ready to be submitted are not archived; they remain in the database until you submit or delete them. Forms with I (Incomplete) status that were created before the archive date are deleted are not saved in the archive file. 01/19/12 201

204 Creating an archive To archive forms: 1. If PES is loaded on a network, ask all other users to exit PES. 2. From the Tools menu, select Archive, and then select Create. A system message reminds you that all other users must exit PES before forms can be archived. 3. Select OK. A system message reminds you that all forms for the archive period with I (Incomplete) status will be deleted. 4. Select Yes. The Archive Forms dialog box opens. 5. Select each form type that you want to archive. If you want to archive all types, select Select All. 6. Adjust the age of the forms to be archived if necessary. (This change applies only to this archiving session. The Retention setting is not changed.) 7. Change the path and/or file name of the archive file to be created, if necessary. 8. Select OK. A system message informs you when the archive is complete. 9. Select OK to close the message. Select OK again to close the Archive Forms window. 01/19/12 202

205 Restoring an archive Forms that have been archived and then restored have A (Archived) status. You cannot change these forms; but you can view them, print them in reports, and copy them as the basis for new transactions. To move forms from an archive file back into the database: 1. If PES is loaded on a network, ask all other users to exit PES. 2. From the Tools menu, select Archive, and then select Restore. The Restore Forms dialog box opens. 3. Type the path and name of the archive file that you want to restore or use the browse button to look for the file. 4. Select Next. A list of available form types opens. 5. Select the form type that you want to restore. If the archive contains no forms of that type, a system message opens. Otherwise, the available forms are listed. 6. Select Next. 7. Select Restore all forms, and then select Finish. OR Select Restore only selected forms. Select the forms you want to restore, and then select Finish. A system message informs you when the restoration is complete. 8. Select OK to close the message. Select OK again to close the Restore Forms window. 01/19/12 203

206 base Recovery Use the base Recovery tool to work with EDI help Desk personnel to fix problems with the database. base Recovery includes the following commands: Compact Repair Unlock Compact Use Compact to make database files smaller and better organized. Each time you delete a form, empty space is created in the database where that form used to be. The Compact command releases the empty space to be used again. To compact the database: Repair 1. If PES is loaded on a network, ask all other users to exit PES. 2. From the Tools menu, select base Recovery, and then select Compact. System messages show the progress of the procedure. 3. When the procedure is complete, select OK to close the message. To repair the database: 1. If PES is loaded on a network, ask all other users to exit PES. 2. From the Tools menu, select base Recovery, and then select Repair. System messages show the progress of the procedure. 3. When the procedure is complete, select OK to close the message. 4. Compact the database. (See Compact.) 01/19/12 204

207 Unlock A system error can cause the database to lock. To unlock the database: 1. From the Tools menu, select base Recovery, and then select Unlock. A system message opens, indicating that the database is unlocked. 2. Select OK to close the message. 01/19/12 205

208 Change Password PES notifies you when it is time to change your password, based on the setting you establish in the Retention option. (See Options.) The default setting is 30 days. You also should change your password any time you think it may have been discovered by an unauthorized person. To change your password: 1. On the Tools menu, select Change Password. The Logon window opens with your user ID pre-filled. Password Requirements Passwords are not case-sensitive. A password can be any combination of alpha, numeric, and special characters. A password must be 5-10 characters in length. 2. In the Old Password field, type your current password. In the New Password and Rekey New Password fields, type the password you want to use. 3. From the list in the Question field, select a security question. In the Answer and Rekey Answer fields, type the answer to the question. 4. Select OK. The system notifies you that your password has been updated. 5. Select OK to close the message. 01/19/12 206

209 Options The following options (identified by tabs in the Options window) must be set up the first time you use PES: Batch, Web, and Retention. To access the Options window after the initial setup, on the Tools menu, select Options. Batch 1. Select the Batch tab. 2. In the Web Logon ID field, type your Submitter ID. In the Web Password field, type your password which will be displayed as asterisks. The Web Logon ID and password are used for web submission only. This password does not expire. 3. To obtain a WebBBS submitter ID and password for new users or a WebBBS password which can be used with your existing submitter ID, go to the Arkansas Medicaid website at and click on PROVIDER, and then click the HIPAA link to access Submitter Registration. This password expires every 90 days but it is recommended to change your password prior to day 90 because on day 91, your account will be locked. When utilizing web batch submission (sending or receiving), you will be prompted to change your password if you are within 30 days of expiration. A window will appear allowing you to change the web submission password. If you choose, you may change your web submission password at 4. Select the correct Entity Type Qualifier for the facility. 1 - Person (individual provider) 2 - Non-Person (group or facility) 04/19/12 207

210 5. In the Submitter Last/Org Name field, if the entity type is a person, type the last name of the provider. If the entity type is a nonperson, type the organization name of the facility or group. 6. In the Submitter First Name field, if the entity type is a person, type the first name of the provider. 7. In the Contact Phone # field, type the 10-digit telephone number at which the submitter can be reached. 04/19/12 208

211 Web PES uses the information on the Web tab to transmit transactions to Arkansas Medicaid via the internet 1. A check in the Use Microsoft Internet Explorer Pre-config Settings box indicates use of Microsoft Internet Explorer configuration settings for connecting to the internet. This box is checked as a default and is the recommended option for internet batch submission. 2. Select the radio button for LAN or Modem as a Connection Type to indicate how the internet connection is being established. The selection of one of the radio buttons is required if the Use Microsoft Internet Explorer Pre-config Settings box is unchecked. 3. Check the Use Proxy Server box when a proxy server is used to connect to the internet. This field is optional. 4. Select the Dialup Network from list provided in the drop down box when the connection type is modem. This field is required if modem was selected as a Connection Type. 5. Enter the address (Universal Resource Locator or URL) of the proxy server in the Proxy Information Address field. This field is required if Use Proxy Server box is checked. 6. In the HTTP Port field, enter the URL (Universal Resource Locator) address of the proxy server. This field is required if Use Proxy Server box is checked. 7. In the HTTPS Port field, enter the port number of the proxy server used for secure Hyper-text Transfer Protocol (HTTPS) communication. This field is required if Use Proxy Server box is checked and the HTTP Port is field is blank. 8. In the Proxy Bypass field, enter the address (URLs) that do not use the proxy server. 9. Providers should default to P in the Environmental Ind field. Test environment indicator T is for HP use only. 01/19/12 209

212 Retention Use the Retention tab to confirm default settings or modify settings for the following PES features. Archive Days Max Batch Max Verify Number of days transactions are accumulated before you are prompted to archive data. If you submit large volumes of claims, archive data every 30 to 60 days. (Default: 30; Maximum: 999) Number of batches retained in the Resubmission option of the Communication menu. Items on the Batch list are deleted on a firstin/first-out basis. (Default: 25; Maximum: 999) Number of response files to be stored on your computer. Downloaded files are deleted on a first-in/first-out basis. (Default: 25; Maximum: 999) Max Log Number of communication log backup files to be retained. (Default: 25; Maximum: 999) Password Expiration Days Number of days before password expires.(default: 30; Maximum: 99) 1. Select OK to save Retention settings. 01/19/12 210

213 Security Use the Security menu to assign and delete user IDs and reset passwords. The Security menu has only one command: Security Maintenance. Security Maintenance You can access Security Maintenance only if your authorization level is 3 (Administrator). To perform security maintenance, 1. On the Security menu, select Security Maintenance. The Security Maintenance window opens with all data-entry fields blank. Information for all current users is listed at the bottom of the screen. 2. To change the settings for an existing user, select that user in the list at the bottom of the screen. The data-entry fields are filled with the user s data. Change the user s ID, password, and/or authorization level, and then select Save. OR To add a new user, complete the data-entry fields as follows. User ID Password Alpha or numeric characters or both. Any combination of alpha, numeric, and special characters. A password 01/19/12 211