20 CAR Part 638 — Portable X-Ray Services Provider Manual

Chapter XV

Subchapter B

20 CAR pt. 638 Portable X-Ray Services Provider Manual {#sec-20-car-pt.-638 omnilex-key=us-ar-regs-official--title-20-part-638--20 CAR pt. 638}

Portable X-Ray Section II Section II-1 SECTION II - PORTABLE X-RAY SERVICES CONTENTS

200.000 PORTABLE X-RAY SERVICES GENERAL INFORMATION 201.000 Arkansas Medicaid Participation Requirements for Portable X-Ray Providers 201.100 Portable X-Ray Providers in Arkansas and Bordering States 201.101 Electronic Signatures 201.200 Providers of Portable X-Ray Services in States Not Bordering Arkansas 202.000 Documentation Required of All Medicaid Providers 202.100 Records Providers of Portable X-Ray Services Are Required to Keep 210.000 PROGRAM COVERAGE 211.000 Introduction 213.000 Scope 214.000 Benefit Limits 214.100 Extension of Benefits for Portable X-Ray Services 214.110 Completion of Form DMS-671, “Request For Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services” 214.120 Documentation Requirements for Extension of Benefits Request 214.200 Administrative Reconsideration and Appeals 214.210 Reserved 215.000 Exclusions 220.000 PRIOR AUTHORIZATION 230.000 REIMBURSEMENT 231.000 Method of Reimbursement 231.010 Fee Schedules 232.000 Rate Appeal Process 240.000 BILLING PROCEDURES 241.000 Introduction to Billing 242.000 CMS-1500 Billing Procedures 242.100 CPT Procedure Codes 242.110 Transportation of Portable X-Ray Services 242.200 National Place of Service (POS) 242.210 National Place of Service (POS) Codes 242.300 Billing Instructions – Paper Only 242.310 Completion of CMS-1500 Claim Form 242.400 Special Billing Procedures

200.000 PORTABLE X-RAY SERVICES GENERAL INFORMATION 201.000 Arkansas Medicaid Participation Requirements for Portable X-Ray Providers 11-1-09 Portable X-ray services providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program: The provider of portable X-ray services must be certified by the Department of Health as a Title XVIII (Medicare) participant. A copy of the current certification must accompany the provider application and Medicaid contract. 201.100 Portable X-Ray Providers in Arkansas and Bordering States 11-1-06 A. Providers in Arkansas and the six bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas) may be enrolled in the Medicaid Program as routine

Portable X-Ray Section II Section II-2 services providers if they meet all Arkansas Medicaid participation requirements outlined above. B. Reimbursement may be available for covered services in the Medicaid Program. Claims must be filed according to billing procedures included in this manual. 201.101 Electronic Signatures 10-8-10 Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code § 25-31-103 et seq. 201.200 Providers of Portable X-Ray Services in States Not Bordering Arkansas 3-1-11 A. Providers in states not bordering Arkansas may enroll in the Arkansas Medicaid program as limited services providers only after they have provided services to an Arkansas Medicaid eligible beneficiary and have a claim or claims to file with Arkansas Medicaid. To enroll, a non-bordering state provider must download an Arkansas Medicaid application and contract from the Arkansas Medicaid website and submit the application, contract and claim to Arkansas Medicaid Provider Enrollment. A provider number will be assigned upon approval of the provider application and the Medicaid contract. View or print the provider enrollment and contract package (Application Packet). View or print Provider Enrollment Unit contact information. B. Limited services providers remain enrolled for one year.

1. If a limited services provider provides services to another Arkansas Medicaid beneficiary during the year of enrollment and bills Medicaid, the enrollment may continue for one year past the most recent claim’s last date of service, if the enrollment file is kept current.
2. During the enrollment period, the provider may file any subsequent claims directly to the Medicaid fiscal agent.
3. Limited services providers are strongly encouraged to file subsequent claims through the Arkansas Medicaid website because the front-end processing of web-based claims ensures prompt adjudication and facilitates reimbursement. 202.000 Documentation Required of All Medicaid Providers 11-1-09 See Section 140.000 for detailed documentation, record keeping and records retention requirements. 202.100 Records Providers of Portable X-Ray Services Are Required to Keep 11-1-06 Providers of portable X-ray services are required to maintain the following records. A. Provider certification by the Arkansas Division of Health as a Title XVIII (Medicare) participant. B. A copy of the provider application and Medicaid contract to participate in the Arkansas Medicaid Program. C. Written contracts between contract personnel and the provider. D. Statistical, fiscal and other records necessary for reporting and accountability. E. The original order signed by the patient’s physician requesting portable X-ray services.

Portable X-Ray Section II Section II-3 F. The diagnosis of the patient to verify the necessity for the service.

210.000 PROGRAM COVERAGE

211.000 Introduction

11-1-06

Arkansas Medicaid assists Medicaid beneficiaries in obtaining medical care within the guidelines

specified in Section I of this manual.

Reimbursement may be made for portable X-ray services within the Medicaid Program

limitations.

213.000 Scope

11-1-06

Portable X-ray services may be covered for a Medicaid beneficiary upon the written order of the

beneficiary’s primary care physician (PCP). The claim for reimbursement must indicate the

name of the physician who ordered the service before payment may be made.

Portable X-ray services may be provided to a beneficiary in his or her place of residence. In the

Portable X-ray Program, the place of residence is defined by the Medicaid Program as the

beneficiary’s own dwelling, an apartment or relative’s home, a boarding home, a residential care

facility, a nursing facility or an intermediate care facility for the mentally retarded. Portable X-ray

services are not covered in a hospital.

Portable X-ray services are limited to the following:

1. Skeletal films involving arms and legs, pelvis, vertebral column and skull;
2. Chest films that do not involve the use of contrast media and
3. Abdominal films that do not involve the use of contrast media.

214.000 Benefit Limits

7-1-22

A. Payments for portable X-ray services claims are applied to the radiology/other services

benefit limit of five hundred dollars ($500) per State Fiscal Year (SFY: July 1 through June

30).

B. Diagnostic laboratory services and radiology/other services defined as Essential Health

Benefits by the U.S. Preventive Services Task Force (USPSTF) are exempt from counting

toward either of the two new annual caps.

View or print the essential health benefit procedure codes.

C. Beneficiaries under twenty-one (21) years of age in the Child Health Services/Early and

Periodic Screening, Diagnostic and Treatment (EPSDT) Program, do not have benefit

limits for portable x-ray services.

214.100 Extension of Benefits for Portable X-Ray Services

7-1-22

A. The Medicaid Program’s diagnostic laboratory services benefit limit, and radiology/other

services benefit limit each apply to the outpatient setting.

1. Diagnostic laboratory services benefits are limited to five hundred dollars ($500) per State Fiscal Year (SFY: July 1 through June 30), and radiology/other services benefits are limited to five hundred dollars ($500) per SFY.
2. Radiology/other services include without limitation diagnostic X-rays, ultrasounds, and electronic monitoring/machine tests, such as electrocardiograms (ECG or EKG).

Portable X-Ray Section II Section II-4 3. Diagnostic laboratory services and radiology/other services defined as Essential Health Benefits by the U.S. Preventive Services Task Force (USPSTF) are exempt from counting toward either of the two new annual caps. View or print the essential health benefit procedure codes. B. Requests for extension of benefits for Portable X-ray services must be submitted to DHS or its designated vendor. View or print DHS or its designated vendor contact information for extension of benefits for x-ray services.

1. Requests for extension of benefits are considered only after a claim is filed and is denied because the patient’s benefit limits are exhausted.
2. Submit with the request a copy of the Medical Assistance Remittance and Status Report reflecting the claim’s denial for exhausted benefits. Do not send a claim. C. Benefit extension requests must be received within ninety (90) calendar days of the date of the benefits-exhausted denial. D. Additional information will be requested as needed to process a benefit extension request. Reconsiderations of additionally requested information are not available. Failure to provide requested information within the specified time will result in a technical denial. E. Correspondence regarding benefit extension requests and requests for reconsideration of denied benefit extension requests, does not constitute documentation or proof of timely claim filing. 214.110 Completion of Form DMS-671, “Request For Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services” 7-1-22 A. The Medicaid Program’s diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.
3. Diagnostic laboratory services benefits are limited to five hundred dollars ($500) per State Fiscal Year (SFY: July 1 through June 30), and radiology/other services benefits are limited to five hundred dollars ($500) per SFY.
4. Radiology/other services include without limitation diagnostic X-rays, ultrasounds, and electronic monitoring/machine tests, such as electrocardiograms (ECG or EKG).
5. Diagnostic laboratory services and radiology/other services defined as Essential Health Benefits by the U.S. Preventive Services Task Force (USPSTF) are exempt from counting toward either of the two new annual caps. B. Requests for extension of benefits for clinical services (physician’s visits), outpatient services (hospital outpatient visits), diagnostic laboratory services (diagnostic laboratory tests) and radiology/other services must be submitted to DHS or its designated vendor. View or print DHS or its designated vendor contact information for extension of benefits for how to obtain information regarding submission processes.
6. Consideration of requests for extension of benefits requires correct completion of all fields on the “Request for Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory and Radiology Other Services” form (Form DMS-671). View or print Form DMS-671.
7. Instructions for accurate completion of Form DMS- 671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each Provider Manual.

Portable X-Ray Section II Section II-5

214.120 Documentation Requirements for Extension of Benefits Request 7-1-22 A. The Medicaid Program’s diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

1. Diagnostic laboratory services benefits are limited to five hundred dollars ($500) per State Fiscal Year (SFY: July 1 through June 30), and radiology/other services benefits are limited to five hundred dollars ($500) per SFY.
2. Radiology/other services include without limitation diagnostic X-rays, ultrasounds, and electronic monitoring/machine tests, such as electrocardiograms (ECG or EKG).
3. Diagnostic laboratory services and radiology/other services defined as Essential Health Benefits by the U.S. Preventive Services Task Force (USPSTF) are exempt from counting toward either of the two new annual caps. B. To request extension of benefits for any services with benefit limits, all applicable records that support the medical necessity of extended benefits are required. C. Documentation requirements are as follows.
4. Clinical records must:
   1. Be legible and include records supporting the specific request;
   2. Be signed by the performing provider;
   3. Include clinical, outpatient, and emergency room records for the dates of
   service (in chronological order); d. Include related diabetic and blood pressure flow sheets; e. Include current medication list for the dates of service; f. Include obstetrical record related to current pregnancy; and g. Include clinical indication for diagnostic laboratory and radiology/other services ordered with a copy of orders for diagnostic laboratory and radiology/other services signed by the physician.
5. Radiology/other reports must include: a. Clinical indication for diagnostic laboratory and radiology/other services ordered; b. Signed orders for diagnostic laboratory and radiology/other services; c. Results signed by the performing provider; and d. Current and all previous ultrasound reports, including biophysical profiles and fetal non-stress tests (when applicable). 214.200 Administrative Reconsideration and Appeals 6-1-25 A. Medicaid allows only one (1) reconsideration of an adverse decision. Reconsideration requests must be submitted in accordance with Section 160.000 of Section I of this Manual. B. When the state Medicaid agency or its designee denies a reconsideration request or issues any adverse decision, the beneficiary may appeal and request a fair hearing. A request for a fair hearing must be submitted in accordance with Sections 160.000, 190.000, and 191.000 of Section I of this Manual.

Portable X-Ray Section II

Section II-6

214.210 Reserved

6-1-25

215.000 Exclusions

10-13-03

Medicaid exclusions from coverage as portable X-ray services include the following:

1. Procedures involving fluoroscopy.
2. Procedures involving the use of contrast media.
3. Procedures requiring the administration of a substance to the patient or injection of a

substance into the patient and/or special manipulation of the patient.

D. Procedures requiring special technical competency and/or special equipment or materials.

E. Routine screening procedures.

F. Procedures which are not of a diagnostic nature.

G. Medicaid does not cover portable X-ray services in a hospital.

220.000 PRIOR AUTHORIZATION 10-13-03 Prior authorization is not applicable to portable X-ray services.

230.000 REIMBURSEMENT

231.000 Method of Reimbursement 10-13-03 Reimbursement for portable X-ray services is made at the lower of (a) the provider’s actual charge for the service or (b) the allowable fee from the state’s physician fee-schedule based on reasonable charge. Medicaid will reimburse the portable X-ray provider for the technical component of the procedure and for transportation of the X-ray equipment and personnel to the home or nursing home. The physician who does the interpretation of the X-ray must bill his charges separately. Refer to Section 240.000 of this manual for billing instructions and procedure codes. 231.010 Fee Schedules 12-1-12 Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at https://medicaid.mmis.arkansas.gov/ under the provider manual section. The fees represent the fee-for-service reimbursement methodology. Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined. Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed. Information may be changed or updated at any time to correct a discrepancy and/or error. Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum. 232.000 Rate Appeal Process 11-1-06 A provider may request reconsideration of a Program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed.

Portable X-Ray Section II Section II-7 Regardless of the Program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the Program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the Program/Provider conference. When the provider disagrees with the decision of the Assistant Director, Division of Medical Services, the provider may appeal the question to a standing rate review panel established by the Director of the Division of Medical Services. The rate review panel will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Health and Human Services (DHHS) management staff, who will serve as chairperson. The request for review by the rate review panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director of the Division of Medical Services. The rate review panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.

240.000 BILLING PROCEDURES

241.000 Introduction to Billing 7-1-20 Podiatrist providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one (1) beneficiary. Section III of this manual contains information about available options for electronic claim submission. 242.000 CMS-1500 Billing Procedures

242.100 CPT Procedure Codes 2-1-22 The following CPT procedure codes are applicable to portable X-ray services: Chest films not involving the use of contrast media: Abdominal films not involving the use of contrast media: Skeletal films involving arms and legs, pelvis, vertebral column and skull: View or print the procedure codes for Portable X-ray services. 242.110 Transportation of Portable X-Ray Services 2-1-22 View or print the procedure codes for Portable X-ray services. Procedure code represents the mileage and setup. If more than one Medicaid patient is seen at a place of service, the Medicaid maximum must be divided by the number of Medicaid patients seen. 242.200 National Place of Service (POS) 7-1-07 242.210 National Place of Service (POS) Codes 7-1-07 Electronic and paper claims now require the same National Place of Service code.

Portable X-Ray Section II Section II-8 Place of Service POS Codes Patient’s Home 12 Nursing Facility 32 Skilled Nursing Facility 31

242.300 Billing Instructions – Paper Only 11-1-17 Bill Medicaid for professional services with form CMS-1500. The numbered items in the following instructions correspond to the numbered fields on the claim form. View a sample form CMS- 1500. Carefully follow these instructions to help the Arkansas Medicaid fiscal agent efficiently process claims. Accuracy, completeness, and clarity are essential. Claims cannot be processed if necessary information is omitted. Forward completed claim forms to the Claims Department. View or print the Claims Department contact information. NOTE: A provider delivering services without verifying beneficiary eligibility for each date of service does so at the risk of not being reimbursed for the services. 242.310 Completion of CMS-1500 Claim Form 2-1-22

Field Name and Number Instructions for Completion

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

Portable X-Ray Section II Section II-9 Field Name and Number Instructions for Completion 6. PATIENT RELATIONSHIP TO INSURED If insurance affects this claim, check the box indicating the patient’s relationship to the insured. 7. INSURED’S ADDRESS (No., Street) Required if insured’s address is different from the patient’s address. CITY STATE ZIP CODE TELEPHONE (Include Area Code)

8. RESERVED Reserved for NUCC use.
9. OTHER INSURED’S NAME (Last name, First Name, Middle Initial) If patient has other insurance coverage as indicated in Field 11d, the other insured’s last name, first name, and middle initial. a. OTHER INSURED’S POLICY OR GROUP NUMBER Policy and/or group number of the insured individual. b. RESERVED Reserved for NUCC use. SEX Not required. c. RESERVED Reserved for NUCC use. d. INSURANCE PLAN NAME OR PROGRAM NAME Name of the insurance company.
10. IS PATIENT’S CONDITION RELATED TO:

a. EMPLOYMENT? (Current or Previous) Check YES or NO. b. AUTO ACCIDENT? Required when an auto accident is related to the services. Check YES or NO. PLACE (State) If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place. c. OTHER ACCIDENT? Required when an accident other than automobile is related to the services. Check YES or NO. d. CLAIM CODES The “Claim Codes” identify additional information about the beneficiary’s condition or the claim. When applicable, use the Claim code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved Condition Codes is found at www.nucc.org under Code Sets. 11. INSURED’S POLICY GROUP OR FECA NUMBER Not required when Medicaid is the only payer. a. INSURED’S DATE OF BIRTH Not required.

Portable X-Ray Section II Section II-10 Field Name and Number Instructions for Completion SEX Not required. b. OTHER CLAIM ID NUMBER Not required. c. INSURANCE PLAN NAME OR PROGRAM NAME Not required. d. IS THERE ANOTHER HEALTH BENEFIT PLAN? When private or other insurance may or will cover any of the services, check YES and complete items 9, 9a and 9d. Only one box can be marked. 12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE Enter “Signature on File,” “SOF” or legal signature. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE Enter “Signature on File,” “SOF” or legal signature. 14. DATE OF CURRENT: ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP) Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident.

Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period. 15. OTHER DATE Enter another date related to the beneficiary’s condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines The “Other Date” identifies additional date information about the beneficiary’s condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation. 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION Not required. 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE Name and title of referral source, whether an individual (such as a PCP) or a clinic or other facility. 17a. (blank) Not required. 17b. NPI Enter NPI of the referring physician.

Portable X-Ray Section II Section II-11 Field Name and Number Instructions for Completion 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Not applicable to portable X-ray. 19. ADDITIONAL CLAIM INFORMATION Identifies additional information about the beneficiary’s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.org for qualifiers. 20. OUTSIDE LAB? Not required. $ CHARGES Not required. 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Enter the applicable ICD indicator to identify which version of ICD codes is being reported. Use “9” for ICD-9-CM Use “0” for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the appropriate International Classification of Diseases (ICD). List no more than 12 diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity. 22. RESUBMISSION CODE Reserved for future use. ORIGINAL REF. NO. Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy. 23. PRIOR AUTHORIZATION NUMBER The prior authorization or benefit extension control number if applicable. 24A. DATE(S) OF SERVICE The “from” and “to” dates of service for each billed service. Format: MM/DD/YY.

1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month.
2. Providers may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of the service on each day of the date sequence. B. PLACE OF SERVICE Two-digit national standard place of service code. See Section 242.200 for codes. C. EMG Enter “Y” for “Yes” or leave blank if “No.” EMG identifies if the service was an emergency. D. PROCEDURES, SERVICES, OR SUPPLIES

Portable X-Ray Section II Section II-12 Field Name and Number Instructions for Completion CPT/HCPCS Enter the correct CPT or HCPCS procedure code from Sections 242.100 through 242.110. MODIFIER Modifier(s) if applicable. E. DIAGNOSIS POINTER Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The “Diagnosis Pointer” is the line letter from Item Number 21 that relates to the reason the service(s) was performed. F. $ CHARGES The full charge for the service(s) totaled in the detail. This charge must be the usual charge to any client, patient, or other recipient of the provider’s services. G. DAYS OR UNITS The units (in whole numbers) of service(s) provided during the period indicated in Field 24A of the detail. H. EPSDT/Family Plan Enter E if the services resulted from a Child Health Services (EPSDT) screening/referral. I. ID QUAL Not required. J. RENDERING PROVIDER ID # Enter the 9-digit Arkansas Medicaid provider ID number of the individual who furnished the services billed for in the detail or NPI Enter NPI of the individual who furnished the services billed for in the detail. 25. FEDERAL TAX I.D. NUMBER Not required. This information is carried in the provider’s Medicaid file. If it changes, please contact Provider Enrollment. 26. PATIENT’S ACCOUNT N O. Optional entry that may be used for accounting purposes; use up to 16 numeric or alphabetic characters. This number appears on the Remittance Advice as “MRN.” 27. ACCEPT ASSIGNMENT? Not required. Assignment is automatically accepted by the provider when billing Medicaid. 28. TOTAL CHARGE Total of Column 24F—the sum all charges on the claim. 29. AMOUNT PAID Enter the total of payments previously received on this claim. Do not include amounts previously paid by Medicaid. *Do not include in this total the automatically deducted Medicaid or ARKids First-B co-payments. 30. RESERVED Reserved for NUCC use.

Portable X-Ray Section II

Section II-13

Field Name and Number Instructions for Completion

31. SIGNATURE OF PHYSICIAN

OR SUPPLIER INCLUDING

DEGREES OR

CREDENTIALS

The provider or designated authorized individual

must sign and date the claim certifying that the

services were personally rendered by the provider or

under the provider’s direction. “Provider’s signature”

is defined as the provider’s actual signature, a rubber

stamp of the provider’s signature, an automated

signature, a typewritten signature, or the signature of

an individual authorized by the provider rendering the

service. The name of a clinic or group is not

acceptable.

32. SERVICE FACILITY

LOCATION INFORMATION

If other than home or office, enter the name and

street, city, state, and zip code of the facility where

services were performed.

1. (blank) Not required.
2. (blank) Not required.

33. BILLING PROVIDER INFO &

PH #

Billing provider’s name and complete address.

Telephone number is requested but not required.

a. (blank) Enter NPI of the billing provider or

b. (blank)

Enter the 9-digit Arkansas Medicaid provider ID

number of the billing provider.

242.400 Special Billing Procedures 10-13-03 Not applicable to this program.

History

• History: Ark. R. 2025-3 (eff. June 1, 2025)