20 CAR Part 652 — Targeted Case Management for Juveniles in Public Institutions

Chapter XV

Subchapter B

20 CAR pt. 652 Targeted Case Management for Juveniles in Public Institutions {#sec-20-car-pt.-652 omnilex-key=us-ar-regs-official--title-20-part-652--20 CAR pt. 652}

Targeted Case Management for Juveniles in Public Institutions Section II

SECTION II –TARGETED CASE MANAGEMENT FOR JUVENILES IN PUBLIC INSTITUTIONS CONTENTS

200.000 TARGETED CASE MANAGEMENT FOR JUVENILES IN PUBLIC INSTITUTIONS GENERAL INFORMATION

201.000 Scope and Eligibility for Targeted Case Management Services for Eligible Juveniles 201.100 Arkansas Medicaid Participation Requirements for Providers of Targeted Case Management for Juveniles in Public Institutions 201.200 Participation Requirements for Individual, Rendering Providers of Targeted Case Management for Beneficiaries Who Are Eligible Juveniles in Public Institutions as Defined in Section 5121 of the Consolidated Appropriations Act of 2023 201.300 Participation Requirements for Group Providers of Targeted Case Management for Beneficiaries Who Are Eligible Juveniles in Public Institutions as defined in Section 5121 of the Consolidated Appropriations Act of 2023 201.400 Targeted Case Management Providers in Bordering and Non-Bordering States 201.500 The Role of the Child Health Services (EPSDT) Program 220.000 PROGRAM COVERAGE 220.100 Covered Case Management Services for Eligible Juveniles 220.200 Exclusions 220.300 Documentation in Beneficiary Files 220.400 Electronic Signatures 220.500 Requirements for Time Records and the Tickler System 220.600 Description of Services 220.700 Assessment and Service Plan Development 220.800 Service Management/Referral and Linkage 220.900 Service Monitoring/Service Plan Updating 221.000 Benefit Limits 230.000 REIMBURSEMENT 230.100 Method of Reimbursement 230.200 Rate Appeal Process 240.000 BILLING PROCEDURES 240.100 Introduction to Billing 240.200 CMS-1500 Billing Procedures 240.300 Targeted Case Management Procedure Codes 240.400 National Place of Service (POS) Codes 240.500 Billing Instructions — Paper Claims Only 240.600 Completion of CMS-1500 Claim Form

200.000 TARGETED CASE MANAGEMENT FOR JUVENILES IN PUBLIC INSTITUTIONS GENERAL INFORMATION

201.000 Scope and Eligibility for Targeted Case Management Services for Eligible Juveniles 7-1-26 A. “Eligible juveniles”, as defined in section 5121 of the Consolidated Appropriations Act of 2023, includes children and youth who are incarcerated after adjudication and are:

1. Under twenty-one (21) years of age determined eligible in any Medicaid eligibility group; or
2. Between eighteen (18) and twenty-six (26) years of age and eligible for Medicaid under the mandatory former foster care eligibility group.

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B. Targeted Case Management assists Eligible Juveniles in accessing all medical, social, educational, and other services appropriate to his or her needs with the goal of transitioning the Eligible Juvenile out of the carceral facility and into a stable home and community-based setting.

1. Targeted case management services for eligible juveniles in public institutions must be provided during the thirty (30) days prior to release (or not later than one (1) week, or as soon as practicable, after release) and for at least thirty (30) days following release.
2. See section 221.000 for information on extension of benefits beyond the thirty-day post-release period. C. A targeted case manager may maintain a maximum active caseload of fifty (50) eligible juveniles at a time. D. If a temporary situation arises based on a filled position becoming temporarily vacant and hiring for the position is in progress, a case manager may exceed the maximum of fifty (50) active cases for no more than sixty (60) consecutive days. E. The maximum number of active cases during a temporary situation, as described above, may not exceed seventy (70). 201.100 Arkansas Medicaid Participation Requirements for Providers of Targeted Case Management for Juveniles in Public Institutions 7-1 -26 Targeted case management (TCM) services providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual to be eligible to participate in the Arkansas Medicaid Program. 201.200 Participation Requirements for Individual, Rendering Providers of Targeted Case Management for Beneficiaries Who Are Eligible Juveniles in Public Institutions as Defined in Section 5121 of the Consolidated Appropriations Act of 2023 7-1 -26 A. Providers of targeted case management services who serve beneficiaries who are eligible juveniles in public institutions as defined in section 5121 of the Consolidated Appropriations Act of 2023 must be:
3. Licensed in the state of Arkansas as one (1) of the following:
   1. A Licensed Clinical Social Worker;
   2. A registered nurse;
   3. A licensed practical nurse;
   4. A licensed social worker; or
   5. A licensed psychiatric technician nurse; or
4. Certified on the basis of a master’s degree or higher by the Arkansas State Board of Education as a school guidance counselor, school psychology specialist, or special education supervisor. B. A copy of the applicant’s license or certification must accompany the provider application and Medicaid contract. C. In addition, qualified targeted case management providers for eligible juveniles must:
5. Be enrolled with Arkansas Medicaid;
6. Have full access to all pertinent records concerning the incarcerated youth’s needs for services, including records from all types of facilities in both the juvenile justice

Targeted Case Management for Juveniles in Public Institutions Section II

system and adult criminal justice system, the Division of Youth Services, and the Division of Children and Family Services; 3. Have established referral systems and demonstrated linkages and referral ability with community resources required by eligible juveniles in public institutions; 4. Have a minimum of one (1) year of experience in providing all core elements of case management services to the target population; 5. Ensure quality services in accordance with state and federal requirements; 6. Have a financial management capacity and system that provides documentation of services and costs in conformity with generally accepted accounting principles; and 7. Have a capacity to document and maintain individual case records in accordance with state and federal requirements. 201.300 Participation Requirements for Group Providers of Targeted Case Management for Beneficiaries Who Are Eligible Juveniles in Public Institutions as defined in Section 5121 of the Consolidated Appropriations Act of 2023 7-1-26 If a case manager is a member of a group, each individual case manager and the group must both enroll according to the following criteria: A. Each individual case manager within the group must enroll following the criteria established in Sections 201.100 and 201.200. B. All group providers are “pay to” providers only. The service must be performed and billed by a Medicaid-enrolled case manager within the group. 201.400 Targeted Case Management Providers in Bordering and Non- Bordering States 7-1-26 The Arkansas Medicaid Targeted Case Management Program is limited to in-state providers only. 201.500 The Role of the Child Health Services (EPSDT) Program 7-1-26 A. The Child Health Services (EPSDT) program is a federally mandated child health component of Medicaid. It is designed to bring comprehensive health care to individuals eligible for medical assistance from birth up to their twenty-first birthday. The purpose of this program is to detect and treat health problems in the early stages and to provide preventive health care, including necessary immunizations. Child Health Services (EPSDT) combines case management and support services with screening, diagnostic, and treatment services delivered on a periodic basis. B. As provided in section 5121 of the Consolidated Appropriations Act of 2023, TCM providers must provide eligible juveniles with any screening and diagnostic services that meet reasonable standards of medical and dental practice in accordance with EPSDT requirements:

1. In the thirty (30) days prior to release from a public institution; or
2. Within one (1) week or as soon as practicable after release from a public institution.
   3. EPSDT treatment services are not required prior to release.
   4. TCM providers are encouraged to refer to the EPSDT provider manual for additional
   information regarding covered services under EPSDT. 220.000 PROGRAM COVERAGE

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220.100 Covered Case Management Services for Eligible Juveniles 7-1 -26 The following are required case management services for Eligible Juveniles: A. Comprehensive needs assessments, including for medical, educational, social, or other services.

1. This includes planning for any Medicaid-covered screening and diagnostic services that the juvenile may receive pre-release. a. For eligible juveniles under twenty-one (21) years of age, these services will be provided in the same manner in which EPSDT services are provided for youth under age twenty-one (21) who are not incarcerated. b. For eligible juveniles age twenty-one (21) and older, screening services will be covered when they are medically necessary to determine existence of a physical or behavioral health illness or condition as well as diagnostic services when a screening service indicates the need for further evaluation and when such diagnostic services are otherwise medically necessary. B. Development of a person-centered care plan—including social, educational, and other underlying needs, such as developing safe decision-making skills or building relationships. C. Referrals and related activities (e.g., scheduling initial post-release appointments, coordinating transition to PASSE services, as appropriate) to link individuals to needed services when in the community. D. Monitoring and follow-up activities (e.g., follow-up with service providers) to ensure the care plan is implemented, including transfer of care if another case manager is to be involved upon release or after the mandatory thirty-day post-release service period. 220.200 Exclusions 7-1 -26 Services that are not appropriate for targeted case management services and are not covered by the Arkansas Medicaid Program include without limitation: A. The actual provision of services or treatment. Examples include without limitation:
2. Treatment for mental health, behavioral health, or chronic conditions;
3. Training in daily living skills;
4. Training in work skills, social skills, and/or exercise;
5. Grooming and other personal care services;
6. Training in housekeeping, laundry, cooking;
7. Transportation services (Arranging for transportation for a beneficiary is covered.);
8. Counseling and/or crisis intervention services;
9. Delivery of services or goods, such as wheelchairs, air conditioners, canes commodities, etc.; and
10. Inspection of services or goods, such as wheelchairs, wheelchair ramps, air conditioners, installation of air conditioners, commodities, etc. B. Services that go beyond assisting individuals in gaining access to needed services. Examples include without limitation:
11. Supervisory activities, including supervisory duties required in other programs such as personal care and home health;
12. Paying bills and/or balancing the beneficiary’s checkbook;

Targeted Case Management for Juveniles in Public Institutions Section II

3. Delivering application forms, paperwork, evaluations and reports;
4. Observing a beneficiary receiving a service, e.g., physical therapy, speech therapy, classroom instruction;
5. Escorting beneficiaries to scheduled medical appointments;
6. Home visits to observe the beneficiary and family’s interactions or the condition of the home for child or adult protection purposes;
7. Verifying Medicaid eligibility through telephone calls, AEVCS, or by any other means; and
8. Travel and/or waiting time. C. Case management services that duplicate services provided by public agencies or private entities under other program authorities for the same purpose. For example, targeted case management services provided to foster children that duplicate services provided by a public agency, such as home visits for purposes of reunification. 220.300 Documentation in Beneficiary Files 7-1 -26 A. The targeted case manager must develop and maintain sufficient written documentation to support each service billed. Written description of services provided must emphasize how the goals and objectives of the service plan are being met or are not being met. All entries in a beneficiary’s file must be signed and dated by the targeted case manager who provided the service, along with the individual’s title. The documentation must be kept in the beneficiary’s case file. B. Documentation must consist of, at a minimum, material that includes:
9. The beneficiary’s name, date of birth, and Medicaid number;
10. The dates of any Child Health Services/EPSDT screens for Eligible Juveniles;
11. Documentation of the Service Plan meeting, including who was in attendance;
12. The Service Plan, and all subsequent updates, signed by the Eligible Juvenile and his or her legal guardian;
13. When applicable, a copy of the original and all updates of the beneficiary’s individualized education plan (IEP);
14. The specific services rendered;
15. The type of service rendered: assessment, plan development, referrals and service management, and/or monitoring;
16. The type of contact: face to face or telephone;
17. The date and actual clock time for the service rendered. This must include the start time and the stop time for each TCM service;
18. The place of service (where the service took place: e.g., office, home);
19. The name of the provider agency, if applicable, and person providing the service;
20. The targeted case manager providing the service must initial each entry in the case file. If the process is automated and all records are computerized, no signature is required. However, there must be an agreement or process in place showing the responsible party for each entry;
21. Updates describing the nature and extent of the referral for services delivered;
22. Description of how TCM services are meeting beneficiary’s Service Plan goals and objectives;

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15. Progress notes on beneficiary’s conditions, whether deteriorating or improving, and the reasons for the change. a. While the targeted case manager may not be considered a medical professional, progress notes are intended to describe a beneficiary’s overall condition, including any changes since the last contact, the reason for the change, etc. b. This requirement is not asking the targeted case manager to diagnose, treat, or offer medical opinions. However, the targeted case manager must record information provided by the beneficiary or others on behalf of the beneficiary that pertains to the service plan goals and progress toward those goals; and
16. Documentation, as described above, is required each time a TCM function is provided for which Medicaid reimbursement will be requested. 220.400 Electronic Signatures 7-1 -26 Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code § 25-31-103 et seq. 220.500 Requirements for Time Records and the Tickler System 7-1 -26
    1. Each TCM must maintain a tickler system for tracking purposes.
    2. The tickler system must track and notify of the following activities:
17. Each active TCM beneficiary; and
18. Medicaid eligibility date. C. It is the responsibility of the case manager to maintain a tickler system, as described above, for those beneficiaries in their specific caseload. However, the record keeping requirements and documentation requirements must be maintained in the beneficiary’s file. 220.600 Description of Services 7-1 -26 Sections 220.700 – 220.900 detail targeted case management services that must be provided by a targeted case management provider. 220.700 Assessment and Service Plan Development 7-1 -26 A. Assessment is performed for the purpose of collecting information about the beneficiary’s situation and functioning and to determine and identify the beneficiary’s problems and needs. B. The TCM assessment is a comprehensive assessment that includes medical, social, educational, and other services. It addresses all facets of the individual’s everyday life in determining how any problem or need might be met and what services are available in the individual’s community. C. This component includes activities that focus on needs identification. Activities, at a minimum, include the assessment of an eligible beneficiary to determine the need for any medical, dental, behavioral, educational, social, or other services. Specific assessment activities include:
19. Taking beneficiary history;
20. Identifying the needs of the beneficiary;
21. Completing related documentation; and

Targeted Case Management for Juveniles in Public Institutions Section II

4. Gathering information from other sources, such as family members, medical providers, social workers, and educators, if necessary, to form a complete assessment of the Medicaid-eligible beneficiary. D. Service plan development builds on the information collected through the assessment phase and includes ensuring the active participation of the Medicaid-eligible beneficiary or their authorized representative. The goals and actions in the care plan must address medical, social, educational, and other services needed by the Medicaid-eligible beneficiary. Service plans must:
5. Be specific and explain each service needed by the beneficiary;
6. Include all services, regardless of payment source;
7. Include support services available to the beneficiary from family, community, church, or other support systems and what needs are met by these resources; and
8. Identify immediate, short-term, and long-term ongoing needs as well as a plan of action for how these needs/goals will be met. E. The assessment and the service plan may be accomplished at the same time, during the same visit, or separately, but must occur face-to-face, in person. 220.800 Service Management/Referral and Linkage 7-1 -26 A. This component includes activities that help link Medicaid eligible beneficiaries with medical, social, and educational providers and/or other programs and services that are capable of addressing identified needs and achieving goals specified in the service plan. This includes making referrals to appropriate care and services available in the geographic region of the home or residence of the eligible juvenile, where feasible, to help the eligible individual obtain needed services. B. This component details functions and processes that include contacting service providers selected by the beneficiary and negotiation for the delivery of services identified in the service plan, including scheduling appointments for the eligible juvenile. Contacts with the beneficiary and/or professionals, caregivers, or other parties on behalf of the beneficiary may be a part of service management. C. Targeted case managers are required to link eligible beneficiaries to needed EPSDT and other screenings and ensure the eligible beneficiary has access to needed services identified by those screenings. 220.900 Service Monitoring/Service Plan Updating 7-1 -26 A. The service monitoring and service plan updating component includes activities and contacts that are necessary to ensure the TCM care plan is effectively implemented and adequately addresses the needs of the Eligible Juvenile. B. The activities and contacts may be with the Eligible Juvenile, family members, providers, or other entities. C. They must occur as frequently as necessary to help determine such things as:
9. Whether services are being furnished in accordance with the Eligible Juvenile’s Service Plan;
10. The adequacy of the services in the Service Plan;
11. Whether progress is being made toward the goals and objectives of the Service Plan; and
12. Changes in the needs or status of the Eligible Juvenile.

Targeted Case Management for Juveniles in Public Institutions Section II

D. Monitoring must include monthly contacts with service providers to verify that appropriate services are provided in accordance with the service plan and at least monthly contacts with the Eligible Juvenile to ensure that he or she participates in the service plan and is satisfied with services.

1. A monitoring contact with the beneficiary must be completed monthly. Required contacts with the service providers may be conducted through face-to-face contact or by telephone or video conference.
2. Documentation of monitoring contacts should be dated, signed by the targeted case manager, and filed in the eligible beneficiary’s case record. E. Each monitoring contact must include:
3. Reexamining the Eligible Juvenile’s needs;
4. Identifying changes that have occurred since the previous monitoring contact;
5. Identifying hospitalizations or other extended absences from the home;
6. Updating the Service Plan, as needed;
7. Measuring the Eligible Juvenile’s progress toward Service Plan goals;
8. Making additional referrals and linkages as needed to continue progress on Service Plan goals. 22 1.000 Benefit Limits 7-1-26 A. Targeted case management services will be covered on a per-member per-month basis for eligible juveniles who are within thirty (30) days of their scheduled date of release from a public institution following adjudication, and for at least thirty (30) days following release. B. An extension of benefits can be requested if continued medically necessary services are needed beyond the thirty-day post-release period.
9. Extension of benefits requests must be sent to the DHS Utilization Review Section. View or print current contact information.
10. For audit purposes, the extension of benefits must be in writing, placed in the beneficiary’s file, and available for auditors.

230.000 REIMBURSEMENT

23 0.100 Method of Reimbursement 7-1-26 A. Reimbursement is based on the lesser of the billed amount or the Title XIX (Medicaid) maximum allowable for each procedure. B. Reimbursement for case management services is based on bundled unit billing. The provider will bill one (1) unit for the first thirty (30) days of service to the individual and one (1) unit for each thirty (30) days of service through the last thirty (30) days post-discharge. DHS publishes the targeted case management fee schedule rates on its website. C. Payment to all governmental and non-governmental providers is a uniform rate for these services unless otherwise approved in the state plan. 23 0.200 Rate Appeal Process 7-1-26 A. 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 twenty (20)

Targeted Case Management for Juveniles in Public Institutions Section II

calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed. Regardless of the Program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the Program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within twenty (20) calendar days of receipt of the request for review or the date of the Program/Provider conference. B. When the provider disagrees with the decision made by 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 (1) member of the Division of Medical Services, a targeted case management provider who serves eligible juveniles, and a member of the Department of Human Services (DHS) Management Staff who will serve as chairperson. C. The request for review by the Rate Review Panel must be postmarked within fifteen (15) calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the question(s) within fifteen (15) calendar days after receipt of a request for such appeal. The panel will hear the question(s) and will submit a recommendation to the Director of the Division of Medical Services.

240.000 BILLING PROCEDURES

24 0.100 Introduction to Billing 7-1-26 A. Targeted case management 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. B. Section III of this manual contains information about available options for electronic claim submission. 24 0.200 CMS-1500 Billing Procedures 7-1-26 24 0.300 Targeted Case Management Procedure Codes 7-1-26 View or print the procedure codes for targeted case management for eligible juveniles. 24 0.400 National Place of Service (POS) Codes 7-1-26 The national place of service code is used for both electronic and paper billing.

Place of Service POS Codes School 03 Prison/Correctional Facility 09 Office 11 Patient’s Home 12 Other Locations 99

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240.500 Billing Instructions — Paper Claims Only 7-1 -26 A. 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. B. 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. C. 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. 240.600 Completion of CMS-1500 Claim Form 7-1 -26

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.
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

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Field Name and Number Instructions for Completion 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. EMPLOYER’S NAME OR SCHOOL NAME Required when items 9 a and d are required. Name of the insured individual’s employer and/or school. 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. SEX Not required. b. OTHER CLAIM ID NUMBER Not required.

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Field Name and Number Instructions for Completion 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, 9c 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 Primary Care Physician (PCP) referral is not required for targeted case management services. 17a. (blank) Not required. 17b. NPI Enter NPI of the referring physician.

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Field Name and Number Instructions for Completion 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES When the serving/billing provider’s services charged on this claim are related to a beneficiary’s or participant’s inpatient hospitalization, enter the individual’s admission and discharge dates. Format: MM/DD/YY. 19. LOCAL EDUCATIONAL AGENCY (LEA) NUMBER Insert LEA number. 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. 24.A. 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 262.200 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

CPT/HCPCS Enter the correct CPT or HCPCS procedure code .

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Field Name and Number Instructions for Completion 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 NO. 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 co-payments. 30. RESERVED Reserved for NUCC use. 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.

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Field Name and Number Instructions for Completion

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.

History

• History: Ark. R. 2026-53 (eff. July 1, 2026)