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

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 codes 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.

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:

Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident.

ILLNESS (First symptom)

OR

INJURY (Accident) OR

PREGNANCY (LMP)

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)/Advanced Practice Registered Nurse (APRN) referral is not required for prosthetics. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title.

17a. (blank)

Not required.

17b. NPI

Enter NPI of the referring physician.

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. 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

CPT/HCPCS

Enter the correct CPT or HCPCS procedure code from Sections 242.100 through 242.195.

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 beneficiary of the provider's services.

G. DAYS OR UNITS

The units (in whole numbers) of service(s) provided during the period indicated in Field 24A of the detail.

H. EPSDT/Family Plan

Enter E if the services resulted from a Child Health Services (EPSDT) screening/referral.

I. ID QUAL

Not required.

J. RENDERING 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.

31. SIGNATURE OF PHYSICIAN/ADVANCED PRACTICE REGISTERED NURSE 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.

a. (blank)

Not required.

b. (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.