Medicaid Arkansas

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Complete all required areas of the UB-04 claim form.

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Print legibly using black ink or use a typewriter.

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When using a printer, make sure the form is lined up correctly to facilitate electronic scanning.

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On the General tab:

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Type – K (Medicaid)

•

Mode – R (Regular)

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On the NPI tab, under IDs to include in Paper Claims, select the Legacy IDs radio button.

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On the Print Variations tab, define the following items for Arkansas Medicaid Hospice (HO), UB-04 Hardcopy.

Locator

Locator Name

Setup

N/A

Specialized Formats

Make no selection.

N/A

Printer

Select the appropriate printer.

N/A

General Rules

Select the following print variations:

FL 5

Federal Tax ID

Select the Suppress printing Federal Tax ID print variation.

FL 6

Statement Cover Period From / Through Date

Select the Use the first and last Dates of Service for each separate claim print variation.

FL 8a

Patient Name

Select the Print Patient Name print variation.

FL 9

Patient Address

Select the Suppress printing Patient Address print variation.

FL 12

Admission Date

Select the Suppress printing Admission Date print variation.

FL 43

Revenue Description

Select the following print variations:

FL 45

Service Date

Select the Suppress printing of the bill date on line 23 print variation.

FL 57

Other Provider Identifier

Select the Print agency's Provider ID without Qualifier print variation.

FL 59a–c

Patient's Relationship to Insured A – C

Select the Print NUBC Relationship Codes effective as of 10/16/03 print variation.

FL 76

Attending Physician's License Number

Select the Print physician's State License Number and 0B Qualifier print variation.

1.

In the left section, select the Arkansas (AR) Medicaid insurance code.

2.

In the Effective Date column, specify the date.

3.

In the FL/Box/Item column, select 4- Type of Bill - Leading Position, paper claims from the drop-down list.

4.

In the Value column, enter '0' for this field locator.

5.

Save your changes.

Field

Description

Assignment of Benefits

and

Release of Information

The Assign Benefits and Rel Infor fields are currently set to 'Y' by default for each carrier. Change to 'N' where applicable.

These fields are located on the HIPAA tab in Patient>General>Payers.

Carrier Code

For Payer (Locator 50), enter the appropriate Arkansas Medicaid assigned ID codes for each insurance carrier (including codes for Arkansas Medicaid and Medicare).

This field is located on the Carrier Codes tab in Administration>Financial>Insurance Codes.

Federal Tax ID

-OR-

Social Security Number

-AND-

Provider Taxonomy Code

-AND-

State License #

For the patient's attending physician, enter either the physician's Federal Tax ID or Social Security Number.

Enter the physician's taxonomy code.

Enter the physician's 10-digit state license number.

These fields are located in Resource>General>Roles.

Provider Taxonomy Code

For taxonomy code, enter the Agency's Provider taxonomy code in the Provider Taxonomy Code field.

This field is located in Administration>Financial>Insurance Codes.

Receiver ID (File Recipient)

For the receiver ID, enter the Arkansas Medicaid receiver ID of "716007869."

This field is located on the EMC tab in Administration>Financial>Insurance Codes.

Receiver Name (Payer)

For payer's receiver name, enter "AR Medicaid" in the Receiver Name (Payer) field.

This field is located on the EMC tab in Administration>Financial>Insurance Codes.

Request for paper EOB

If you want to receive a paper EOB, select the Request for paper EOB check box.

This field is located in Administration>Financial>Insurance Codes.

Submitter ID

For the submitter ID, enter the submitter ID assigned to you by Arkansas Medicaid.

This field is located on the EMC tab in Administration>Financial>Insurance Codes.

Test Submission Indicator

Indicate if this is a test file being sent by selecting or clearing the Test Submission Indicator check box.

This box is located on the EMC tab in Administration>Financial>Insurance Codes.

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In the Locator 14-15 section in Administration>Financial>Insurance Codes>Print Variations, select the Print '3' and '1' Admission Type/Src check box to ensure compliance with the ANSI 5010 Billing Template.

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Ensure that either I or Y is selected for ANSI 5010 in the Rel Infor column in Patient>General>Payers>HIPAA.

Field

Description

Assignment of Benefits

and

Release of Information

The Assign Benefits and Rel Infor fields are currently set to Y by default for each carrier. Change to N where applicable.

These fields are located on the HIPAA tab in Patient>General>Payers.

Carrier Code

For Payer (Locator 50), enter the appropriate Arkansas Medicaid assigned ID codes for each insurance carrier (including codes for Arkansas Medicaid and Medicare).

This field is located on the Carrier Codes tab in Administration>Financial>Insurance Codes.

Federal Tax ID

-OR-

Social Security Number

-AND-

Provider Taxonomy Code

-AND-

State License #

For the patient's attending physician, enter either the physician's Federal Tax ID or Social Security Number.

Enter the physician's taxonomy code.

Enter the physician's 10-digit state license number.

These fields are located in Resource>General>Roles.

Provider Taxonomy Code

For taxonomy code, enter the Agency's Provider taxonomy code in the Provider Taxonomy Code field.

This field is located in Administration>Financial>Insurance Codes.

Receiver ID (File Recipient)

For the receiver ID, enter the Arkansas Medicaid receiver ID of 716007869.

This field is located in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

For payer's receiver name, enter Arkansas Medicaid in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Request for paper EOB

If you want to receive a paper EOB, select the Request for paper EOB check box in Administration>Financial>Insurance Codes.

Submitter ID

For the submitter ID, enter the submitter ID assigned to you by Arkansas Medicaid.

This field is located in Administration>Financial>Insurance Codes>EMC.

Test Submission Indicator

Select or clear the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

>

Complete all required areas of the UB-04 claim form.

>

Use only original UB-04 claim forms with the red drop-out ink or file electronically.

>

When using a printer, make sure the form is lined up correctly to facilitate electronic scanning.

>

The value for all check boxes on the form is X.

>

If a field is not completed, leave the items empty on the form.

>

Do not enter zeros into numeric fields; leave the numeric fields empty unless specified.

>

Claims are split into items based on the Revenue/HCPC Codes.

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Type – K (Medicaid)

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Mode – B (Benefit)

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State – AR (Arkansas)

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Form – UB-04

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In the IDs to include in Paper Claims section, select the Legacy IDs and National Provider IDs (NPI) check box.

>

In the IDs to include in EMC files section, select the National Provider IDs (NPI) check box.

Locator

Locator Name

Setup

N/A

Specialized Formats

Make no selection.

N/A

Printer

Select the appropriate printer.

N/A

General Rules

Select the following print variations:

FL 3a

Patient Control Number

Select the Print Claim ID print variation.

FL 3b

Medical Health Record Number

Select the Print Patient ID print variation.

FL 4

Type of Bill

Enter 0 to indicate the 4-digit Type of Bill using the claim constants at the appropriate level.

FL 5

Federal Tax ID

Select the Suppress printing Federal Tax ID print variation.

FL 6

Statement Cover Period From/Through Dates

Select the Use the first and last Dates of Service for each separate claim print variation.

FL 8

Patient Name/Identifier

Select the Print the middle initial only print variation.

FL 8a

Patient Name

Select the Print Patient Name print variation.

FL 18–28

Condition Code

If needed, enter condition codes in Patient>General>Claim Constants.

FL 31ab–34ab

Occurrence Code

If needed, enter occurrence codes in Patient>General>Claim Constants.

FL 39–41

Value Codes Amounts

Select the Suppress printing Value Code '44' print variation.

Enter value codes and total charge amounts of the claims in Patient>General>Claim Constants.

FL 42

Revenue Code

Enter the appropriate 4-digit revenue codes in the Rev Code column in Administration>Financial>Billing Rates>Ratesfor this insurance.

N/A

Benefit and Hybrid Claims

Select the Line item billing print variation.

FL 51

Health Plan Identification Number

Select the Suppress printing Health Plan ID print variation.

FL 52

Release of Information Certification Indicator

Enter the appropriate code (I or Y) in Patient>General>Claim Constants.

FL 55

Estimated Amount Due

Select the Suppress printing estimated amount due print variation.

FL 57

Other Provider Identifier

Select the following print variations:

FL 58

Insured's Name

Select the Print the middle initial only print variation.

FL 59

Patient's Relationship to Insured

Select the Suppress printing of Patient Relationship print variation.

FL 60

Insured's Unique ID

Select the Only print value for current claim payer line print variation.

FL 61

Insured's Group Name

Select the Print the Insurance Group Name print variation.

FL 69

Admit Diagnosis

Enter the most specific ICD-9-CM diagnosis code that corresponds to the beneficiary's terminal condition in Patient>General>Claim Constants.

FL 76

Attending Physician's License Number

Select the Print physician's State License Number and 0B Qualifier print variation.

FL 78

Other Physician

Enter the 0B qualifier and the referring physician's state license number, last and first name in the FL/Box/Item column in Patient>General>Claim Constants.

Note: When there is no referring physician, enter in FL 78 the same information as in FL 76.

FL 79

Other Provider (Individual) Names and Identifiers

If applicable, enter the 0B Qualifier and the inpatient facility state license number in the second part of the field in Patient>General>Claim Constants.

FL 80

Remarks

If needed, enter remarks in Patient>General>Claim Constants.

Field

Description

Assignment of Benefits

and

Release of Information

The Assign Benefits and Rel Infor fields are currently set to 'Y' by default for each carrier. Change to 'N' where applicable.

These fields are located on the HIPAA tab in Patient>General>Payers.

Federal Tax ID

-OR-

Social Security Number

-AND-

Provider Taxonomy Code

-AND-

State License #

For the patient's attending physician, enter either the physician's Federal Tax ID or Social Security Number.

Enter the physician's taxonomy code.

Enter the physician's 10-digit state license number.

These fields are located in Resource>General>Roles.

Provider Taxonomy Code

For taxonomy code, enter the Agency's Provider taxonomy code in the Provider Taxonomy Code field.
Note: This information is not currently required by Arkansas, but may become a requirement in the future.

This field is located on the General tab in Administration>Financial>Insurance Codes.

Receiver ID (File Recipient)

For the receiver ID, enter the Arkansas Medicaid receiver ID of "716007869."

This field is located on the EMC tab in Administration>Financial>Insurance Codes.

Receiver ID (Payer)

For payer's receiver ID, enter the appropriate ID codes for each carrier (including Arkansas Medicaid and Medicare).

This field is located on the EMC tab in Administration>Financial>Insurance Codes.

Receiver Name (Payer)

For payer's receiver name, enter "AR Medicaid" in the Receiver Name (Payer) field.

This field is located on the EMC tab in Administration>Financial>Insurance Codes.

Request for paper EOB

If you want to receive a paper EOB, select the Request for paper EOB check box.

This field is located on the General tab in Administration>Financial>Insurance Codes.

Submitter ID

For the submitter ID, enter the submitter ID assigned to you by Arkansas Medicaid.

This field is located on the EMC tab in Administration>Financial>Insurance Codes.

Test Submission Indicator

Indicate if this is a test file being sent by selecting or clearing the Test Submission Indicator check box.

This box is located on the EMC tab in Administration>Financial>Insurance Codes.

>

In the Locator 14-15 section in Administration>Financial>Insurance Codes>Print Variations, select the Print '3' and '1' Admission Type/Src check box to ensure compliance with the ANSI 5010 Billing Template.

>

Ensure that either I or Y is selected for ANSI 5010 in the Rel Infor column in Patient>General>Payers>HIPAA.

Field

Description

Assignment of Benefits

and

Release of Information

The Assign Benefits and Rel Infor fields are currently set to 'Y' by default for each carrier. Change to 'N' where applicable.

These fields are located on the HIPAA tab in Patient>General>Payers.

Federal Tax ID

-OR-

Social Security Number

-AND-

Provider Taxonomy Code

-AND-

State License #

For the patient's attending physician, enter either the physician's Federal Tax ID or Social Security Number.

Enter the physician's taxonomy code.

Enter the physician's 10-digit state license number.

These fields are located in Resource>General>Roles.

Provider Taxonomy Code

For taxonomy code, enter the Agency's Provider taxonomy code in the Provider Taxonomy Code field.

Note: This information is not currently required by Arkansas, but may become a requirement in the future.

This field is located on the General tab in Administration>Financial>Insurance Codes.

Receiver ID (File Recipient)

For the receiver ID, enter the Arkansas Medicaid receiver ID of "716007869."

This field is located on the EMC tab in Administration>Financial>Insurance Codes.

Receiver ID (Payer)

For payer's receiver ID, enter the appropriate ID codes for each carrier (including Arkansas Medicaid and Medicare).

This field is located on the EMC tab in Administration>Financial>Insurance Codes.

Receiver Name (Payer)

For payer's receiver name, enter "AR Medicaid" in the Receiver Name (Payer) field located on the EMC tab in Administration>Financial>Insurance Codes.

Request for paper EOB

If you want to receive a paper EOB, select the Request for Paper EOB check box located on the General tab in Administration>Financial>Insurance Codes.

Submitter ID

For the submitter ID, enter the submitter ID assigned to you by Arkansas Medicaid.

This field is located on the EMC tab in Administration>Financial>Insurance Codes.

Test Submission Indicator

Indicate if this is a test file being sent by selecting or clearing the Test Submission Indicator check box located on the EMC tab in Administration>Financial>Insurance Codes.

>

Complete all required areas of the CMS-1500 claim form.

>

Use only original CMS-1500 claim forms with the red drop-out ink or file electronically.

>

When using a printer, make sure the form is lined up correctly to facilitate electronic scanning.

>

The value for all check boxes on the form is X.

>

If a field is not completed, leave the items empty on the form.

>

Do not enter zeros into numeric fields; leave the numeric fields empty unless specified.

>

Type – K (Medicaid)

>

Mode – R (Regular)

>

State – AR (Arkansas)

>

Form – CMS-1500

>

In the IDs to include in Paper Claims section, select the Legacy IDs and National Provider IDs (NPI) check box.

>

In the IDs to include in EMC files section, select the National Provider IDs (NPI) check box.

Locator

Locator Name

Setup

N/A

Printer

Select the appropriate printer.

N/A

General Rules

Select the Make separate claims (with totals) for claims print variation.

FL 10a

Is Patient's Condition Related to Current or Previous Employment

If the patient's condition is related to the current or previous employment, enter Y in the Value field in Patient>General>Claim Constants.

FL 10b

Is Patient's Condition Related to Auto Accident

If the patient's condition is related to an auto accident, enter Y in the Value field in Patient>General>Claim Constants.

FL 10c

Is Patient's Condition Related to Other Accident

If the patient's condition is related to the other accident, enter Y in the Value field in Patient>General>Claim Constants.

FL 11

Insured's Policy Group or FECA Number

Select the Print the Insurance ID print variation.

FL 17

Name of Referring Provider or Other Source

Select the Print the Referral Source print variation.

FL 17a

Other ID #

Select the Print the Referring Physician's Medicaid Provider Number and 1D Qualifier print variation.

FL 19

Reserved for Local Use

When billing for schools, school districts, and education service cooperatives, enter the LEA number of the facility or district providing the service in Patient>General>Claim Constants.

FL 23

Prior Authorization Number

Select the Print prior authorization number print variation.

FL 24

Service Details

Select the Summarize the charges by type of service on consecutive days print variation.

FL 24d

Procedures, Services, or Supplies

Select the Print shift modifiers based on start time of visits. Note: Requires Shift Modifiers to be set up in Billing Rates print variation.

15 minutes of authorized, documented, and logged personal care equals to one unit of personal care aide service.

Providers may not bill for less than 15 minutes of service. However, personal care aide time spent on providing services for a single beneficiary may be summarized during a single 24-hour calendar day, and the sum in minutes may be divided by 15 to calculate the number of service units provided during that day.

Description

Procedure Code

Modifier

Personal Care for a client aged 21 or older, per 15 minutes.

T1019

U3

Personal Care for a client under 21, per 15 minutes (requires prior authorization).

T1019

Personal Care for a client under 21 provided by a school district or education service cooperative, per 15 minutes (requires prior authorization).

T1019

U4

Note: All four locations are listed in the table, but only Client's Home is used for the client's current claims.

FL 31

Signature of Physician or Supplier

Select the Print Authorized Signature and date print variation.

FL 33

Billing Provider Information and Physician Number

Select the Print the agency name, address and phone number print variation.

FL 33b

Billing Provider

Enter the 9-digit Arkansas Medicaid provider ID of the billing provider in Patient>General>Claim Constants or Administration>Financial>Claim Constants.

Field

Description

Annotate Claims

If this is a voided or replaced claim, enter the document control number or the ICN of the original claim through Claims>Process>Annotate Claims.
Note: If your organization uses electronic remittances, then the system will automatically import this number.

Assignment of Benefits

-AND-

Release of Information

These fields are currently set to 'Y' by default for each carrier. Change to 'N' where applicable.

These fields are located on the HIPAA tab in Patient>General>Payers.

Carrier Codes

On the Carrier Codes tab in Administration>Financial>Insurance Codes, enter the primary identifier of each Third Party Payer (including the identifier for North Carolina Medicaid which is 'DNC00').

Federal Tax ID

-OR-

Social Security Number

-AND-

Provider Taxonomy Code

-AND-

Medicaid Provider Number

For the patient's attending physician (referring physician as reported in FL17 on the CMS-1500 (08/05)), enter the doctor's Federal Tax ID.

You must also enter the Provider's Taxonomy Code.

The Medicaid provider number of the physician must be entered as well in the State License No. field.
Note: If the Federal Tax ID field is left blank, the application will automatically write nine zeros for the Tax ID as allowed by Arkansas Medicaid.

These fields are located in Resource>General>Roles.

Insurance Type Code

In the Insurance Type Code field, select the appropriate code identifying the type of insurance policy within a specific insurance program.

This field is located in the Insurance Codes and Insurance Companies windows in Administration>Financial.

Medicare Assign (Medicare Assignment Code)

Currently set to 'A' (Assigned) by default. Select another code from the drop-down list if needed.

This field is located on the HIPAA tab in Patient>General>Payers>Pay Source.

Patient Sign (Patient Signature Code)

If the Release of Information field is set to 'Y', select the appropriate Patient Signature Code if different from 'B' set by default by the system (Signed authorization form for CMS-1500 (08/05), Block 12/13 on file).

This field is located on the HIPAA tab in Patient>General>Payers>Pay Source.

Place of Service Codes

For electronic claims, Arkansas Medicaid requires that different Place of Service Codes be reported than those used in hardcopy claims. The application will automatically translate the Place of Service Codes that you have entered as Billing Rates to the appropriate required code as follows:

Place of Service Codes for Paper Claims vs. Electronic Claims are as follows:

Client's Home

DDS Community Provider Facility

Public School

Other Locations

Program (Special Program Code)

Select '01' (EPSDT) if services are provided under the EPSDT problem.

This field is located on the HIPAA tab in Patient>General>Payers>Pay Source.

Receiver ID (File Recipient)

Enter '716007869' in the Receiver ID (File Recipient) field located on the EMC tab in Administration>Financial>Insurance Codes.

Receiver Name (Payer)

Enter 'Arkansas Medicaid' in the Receiver Name (Payer) field located on the EMC tab in Administration>Financial>Insurance Codes.

Submitter ID

Enter your Agency's assigned Trading Partner ID in the Submitter ID field located on the EMC tab in Administration>Financial>Insurance Codes.

Test Submission Indicator

Indicate if this is a test file sent by selecting or clearing the check box located on the EMC tab in Administration>Financial>Insurance Codes.

Voided or Replacement Claims

Arkansas Medicaid does not accept replacement or voided claims electronically. You can omit these claim types by selecting '2' (Suppress replacements) in the Special Handling field located on the EMC tab in Administration>Financial>Insurance Codes.

Field

Description

Annotate Claims

If this is a voided or replaced claim, enter the document control number or the ICN of the original claim through Claims>Process>Annotate Claims.
Note: If your organization uses electronic remittances, then the system will automatically import this number.

Assignment of Benefits

-AND-

Release of Information

These fields are currently set to 'Y' by default for each carrier. Change to 'N' where applicable.

These fields are located on the HIPAA tab in Patient>General>Payers.

Carrier Codes

On the Carrier Codes tab in Administration>Financial>Insurance Codes, enter the primary identifier of each Third Party Payer (including the identifier for North Carolina Medicaid which is 'DNC00').

Federal Tax ID

-OR-

Social Security Number

-AND-

Provider Taxonomy Code

-AND-

Medicaid Provider Number

For the patient's attending physician (referring physician as reported in FL17 on the CMS-1500 (08/05)), enter the doctor's Federal Tax ID.

You must also enter the Provider's Taxonomy Code.

The Medicaid provider number of the physician must be entered as well in the State License No. field.
Note: If the Federal Tax ID field is left blank, the application will automatically write nine zeros for the Tax ID as allowed by Arkansas Medicaid.

These fields are located in Resource>General>Roles.

Insurance Type Code

In the Insurance Type Code field, select the appropriate code identifying the type of insurance policy within a specific insurance program.

This field is located in the Insurance Codes and Insurance Companies windows in Administration>Financial.

Medicare Assign (Medicare Assignment Code)

Currently set to 'A' (Assigned) by default. Select another code from the drop-down list if needed.

This field is located on the HIPAA tab in Patient>General>Payers>Pay Source.

Patient Sign (Patient Signature Code)

If the Release of Information field is set to 'Y', select the appropriate Patient Signature Code if different from 'B' set by default by the system (Signed authorization form for CMS-1500 (08/05), Block 12/13 on file).

This field is located on the HIPAA tab in Patient>General>Payers>Pay Source.

Place of Service Codes

For electronic claims, Arkansas Medicaid requires that different Place of Service Codes be reported than those used in hardcopy claims. The application will automatically translate the Place of Service Codes that you have entered as Billing Rates to the appropriate required code as follows:

Place of Service Codes for Paper Claims vs. Electronic Claims are as follows:

Client's Home

DDS Community Provider Facility

Public School

Other Locations

Program (Special Program Code)

Select '01' (EPSDT) if services are provided under the EPSDT problem.

This field is located on the HIPAA tab in Patient>General>Payers>Pay Source.

Receiver ID (File Recipient)

Enter '716007869' in the Receiver ID (File Recipient) field located on the EMC tab in Administration>Financial>Insurance Codes.

Receiver Name (Payer)

Enter 'Arkansas Medicaid' in the Receiver Name (Payer) field located on the EMC tab in Administration>Financial>Insurance Codes.

Submitter ID

Enter your Agency's assigned Trading Partner ID in the Submitter ID field located on the EMC tab in Administration>Financial>Insurance Codes.

Test Submission Indicator

Indicate if this is a test file sent by selecting or clearing the check box located on the EMC tab in Administration>Financial>Insurance Codes.

Voided or Replacement Claims

Arkansas Medicaid does not accept replacement or voided claims electronically. You can omit these claim types by selecting '2' (Suppress replacements) in the Special Handling field located on the EMC tab in Administration>Financial>Insurance Codes.

>

Type – K (Medicaid)

>

Mode – R (Regular)

>

State – AR (Arkansas)

The use of Modifiers causes prints them directly behind the Procedure Code. This may cause claim rejections because the modifier is not in the correct field on the form.

>

HP Laser Jet 4000 n, driver PCL 6

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HP Laser Jet 5, driver HP Laser Jet 5/5M standard

Field

Description

Annotate Claims

If values other than No are required for Box 10, specify them in Patient>General>Annotate Claims. If any of the check boxes are selected, enter the Accident Date.

Carrier Codes

Carrier Codes are now activated for this format. Be sure to define all carrier codes including Medicaid and Medicare. If there is a special code for carriers without codes, enter it with a blank Insurance Code and Company in the table for this payer.

Billing Rates

(Place of Service Code)

Place of Service or FL 24B. Enter the appropriate Place of Service for each billing rate in Administration>Financial>Billing Rates>Rate tab.

Field

Description

Assignment of Benefits 
-AND-
Rel Infor (Release of Information) 
-AND-
Special Program Code 
-AND-
Medicare Assignment Code

Patient>General>Payers: Assign Benefits (Assignment of Benefits): currently -AND-defaulted to 'Y' for each carrier. Change to 'N' where applicable.
Release of Information: currently defaulted to Patient Signature Code 'Y' for each carrier. Change to 'N' where applicable.
Patient Sign (Patient Signature Code): If the 'Release of -AND-Information' field is set to 'Y', select the appropriate Medicare Assignment Code Patient Signature Code if different from the system set default of 'B' (Signed authorization form for HCFA-1500 Block 12/13 on file).

Program (Special Program Code): Select '01' (EPSDT) if Services are being provided under the EPSDT problem.

Medicare Assign (Medicare Assignment Code): currently set to 'A' (Assigned) by default. Select another code from the drop-down list if needed.

Carrier Codes

For Payer (Locator 50), enter the appropriate Arkansas Medicaid assigned ID codes for each insurance carrier (including codes for Arkansas Medicaid and Medicare).

This field is located on the Carrier Codes tab in Administration>Financial>Insurance Codes.

Federal Tax ID

For the patient's attending (referring physician as reported in -OR-FL17 on the HCFA1500) enter the physician's Federal Tax Social Security Number ID in Resource>General>Roles. You must also enter the -AND-Provider's Taxonomy Code and the Physician's Medicaid Provider Taxonomy Code Provider ID (enter in the State License No field) on this -AND-screen. State License #.

Insurance Type Code

The Insurance Codes and/or Insurance Company windows: In the Insurance Type Code field, select the appropriate code identifying the type of insurance policy within a specific insurance program.

Medicaid ID #

Patient>General>Payers: Enter the Recipient's Medicaid ID number.

Provider ID

Enter the 9-digit provider # assigned by AR Medicaid in the Provider No. field in the Administration>Financial>Insurance Codes.

Receiver ID (File Recipient)

Enter "716007869" in the Receiver ID (File Recipient) field located on the EMC tab in Administration>Financial>Insurance Codes.

Receiver Name (Payer)

Enter "Arkansas Medicaid" in the Receiver Name (Payer) field located on the EMC tab of Administration>Financial>Insurance Codes.

Special Handling

Arkansas Medicaid does not accept Replacement or Voided claims electronically. You can omit these claim types by selecting '2' (Suppress replacements) in the Special Handling field located in Administration>Financial>Insurance Codes>EMC.

Submitter ID

Enter your Agency's assigned Trading Partner ID in the Submitter ID field located on the EMC tab in Administration>Financial>Insurance Codes.

Voided or Replacement Claim

If this is a voided or replaced claim, enter the document control number or the ICN of the original claim through Claims>Process>Annotate Claims.

Note: If your organization uses electronic remittances, then the system will automatically import this number.

Test Submission Indicator

Enter "Arkansas Medicaid" in the Receiver Name (Payer) field located on the EMC tab in Administration>Financial>Insurance Codes.

Place of Service Codes

For electronic claims, Arkansas Medicaid requires that different Place of Service Codes be reported than those used on hardcopy claims. The application will automatically translate the Place of Service Codes that you have entered as Billing Rates to the appropriate required code as follows:

Claims

Paper Claims

Electronic Claims

Client's Home

4

12

DDS Community

5

52

Provider Facility

Public School

S

03

Other Locations

0

99

Field

Description

Assignment of Benefits 
-AND-
Rel Infor (Release of Information) 
-AND-
Special Program Code 
-AND-
Medicare Assignment Code

Patient>General>Payers: Assign Benefits (Assignment of Benefits): Currently -AND-set to 'Y' by default for each carrier. Change to 'N' where applicable.
Release of Information: Currently set to Patient Signature Code 'Y' by default for each carrier. Change to 'N' where applicable.
Patient Sign (Patient Signature Code): If the 'Release of -AND-Information' field is set to 'Y', select the appropriate Medicare Assignment Code Patient Signature Code if different from the default 'B' set by the system (Signed authorization form for HCFA-1500 Block 12/13 on file).

Program (Special Program Code): Select '01' (EPSDT) if the services are being provided under the EPSDT problem.

Medicare Assign (Medicare Assignment Code): Currently set to 'A' (Assigned) by default. Select another code from the drop-down list if needed.

Carrier Codes

For Payer (Locator 50), enter the appropriate Arkansas Medicaid assigned ID codes for each insurance carrier (including codes for Arkansas Medicaid and Medicare).

This field is located on the Carrier Codes tab in Administration>Financial>Insurance Codes.

Federal Tax ID

For the patient's attending (referring physician as reported in -OR-FL17 on the HCFA1500) enter the physician's Federal Tax Social Security Number ID in Resource>General>Roles. You must also enter the -AND-Provider's Taxonomy Code and the Physician's Medicaid Provider Taxonomy Code Provider ID (enter in the State License No field) in the -AND-window. Define the License #.

Insurance Type Code

The Insurance Codes and/or Insurance Company windows: In the Insurance Type Code field, select the appropriate code identifying the type of insurance policy within a specific insurance program.

Medicaid ID #

Enter the Recipient's Medicaid ID number in Patient>General>Payers.

Provider ID

Enter the 9-digit provider number assigned by Arkansas Medicaid in the Provider No. field in Administration>Financial>Insurance Codes.

Receiver ID (File Recipient)

Enter "716007869" in the Receiver ID (File Recipient) field in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter "Arkansas Medicaid" in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Special Handling

Arkansas Medicaid does not accept Replacement or Voided claims electronically. You can omit these claim types by selecting '2' (Suppress replacements) in the Special Handling field in Administration>Financial>Insurance Codes>EMC.

Submitter ID

Enter your Agency's assigned Trading Partner ID in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Voided or Replacement Claim

If this is a voided or replaced claim, enter the document control number or the ICN of the original claim through Claims>Process>Annotate Claims.

Note: If your organization uses electronic remittances, then the system will automatically import this number.

Test Submission Indicator

Enter "Arkansas Medicaid" in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Place of Service Codes

For electronic claims, Arkansas Medicaid requires that different Place of Service Codes be reported than those used on hardcopy claims. The application will automatically translate the Place of Service Codes that you have entered as Billing Rates to the appropriate required code as follows:

Claims

Paper Claims

Electronic Claims

Client's Home

4

12

DDS Community

5

52

Provider Facility

Public School

S

03

Other Locations

0

99