Arkansas Medicaid Provider Electronic Solutions (PES)...

Arkansas Medicaid

Provider Electronic Solutions (PES)

Handbook

A user guide for HP Provider Electronic Solutions Software

v. 2.15

April 19, 2012 (Revised)

HP Arkansas Title XIX Account

500 President Clinton Avenue, Suite 400

Little Rock, Arkansas 72201

(501) 374-6608

Hewlett-Packard and the HP logo are registered in the U.S. Patent and Trademark office.

HP is an equal opportunity employer and values the diversity of its people.

Copyright © 2011 Hewlett-Packard. All rights reserved.

i

Contents Contents ........................................................................................................................................................ i

What is PES? ............................................................................................................................................... 7

How is this handbook organized? ............................................................................................................. 7

Getting started ............................................................................................................................................. 8

System requirements .............................................................................................................................. 9

How to download PES ............................................................................................................................ 9

How to load PES on a single computer ................................................................................................ 10

From the Web ................................................................................................................................ 10

How to load PES on a network ............................................................................................................. 12

Opening PES ........................................................................................................................................ 12

Logging on for the first time .................................................................................................................. 12

Setting up options ................................................................................................................................. 14

Basic skills ............................................................................................................................................ 14

Using the keyboard ........................................................................................................................ 14

Using the mouse ............................................................................................................................ 14

Using the PES window ................................................................................................................... 15

Using menu commands ................................................................................................................. 17

Using command buttons ................................................................................................................ 18

Correcting errors ............................................................................................................................ 19

Closing PES .......................................................................................................................................... 19

Forms ......................................................................................................................................................... 20

270 Eligibility Request .......................................................................................................................... 21

Header............................................................................................................................................ 22

276 Claim Status Request .................................................................................................................... 24

Header 1 ........................................................................................................................................ 25

Header 2 ........................................................................................................................................ 26

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278 Prior Authorization Request ........................................................................................................... 27

Header 1 ........................................................................................................................................ 28

Header 2 ........................................................................................................................................ 30

Service 1 ........................................................................................................................................ 32

Service 2 ........................................................................................................................................ 33

Service 3 ........................................................................................................................................ 35

837 Dental ............................................................................................................................................ 37

Header 1 ........................................................................................................................................ 38

Header 2 ........................................................................................................................................ 40

TPL ................................................................................................................................................. 42

Services ......................................................................................................................................... 44

837 Institutional Inpatient ...................................................................................................................... 46

Header 1 ........................................................................................................................................ 47

Header 2 ........................................................................................................................................ 50

Header 3 ........................................................................................................................................ 52

Header 4 ........................................................................................................................................ 53

Header 5 ........................................................................................................................................ 55

TPL ................................................................................................................................................. 56

Crossover ....................................................................................................................................... 57

Service ........................................................................................................................................... 58

837 Institutional Nursing Home ............................................................................................................ 59

Header 1 ........................................................................................................................................ 60

Header 2 ........................................................................................................................................ 62

Header 3 ........................................................................................................................................ 63

TPL ................................................................................................................................................. 65

Crossover ....................................................................................................................................... 67

Service ........................................................................................................................................... 68

Copying old claims to submit as new claims.................................................................................. 69

iii

837 Institutional Outpatient ................................................................................................................... 70

Header 1 ........................................................................................................................................ 71

Header 2 ........................................................................................................................................ 73

Header 3 ........................................................................................................................................ 75

TPL ................................................................................................................................................. 77

Crossover ....................................................................................................................................... 78

Service ........................................................................................................................................... 79

RX .................................................................................................................................................. 81

837 Professional Medicaid ................................................................................................................... 82

Header 1 ........................................................................................................................................ 83

Header 2 ........................................................................................................................................ 85

Header 3 ........................................................................................................................................ 87

TPL ................................................................................................................................................. 89

Crossover ....................................................................................................................................... 91

Service 1 ........................................................................................................................................ 92

Service 2 ........................................................................................................................................ 94

NET ................................................................................................................................................ 95

RX .................................................................................................................................................. 97

837 Professional BreastCare ................................................................................................................ 98

Header 1 ........................................................................................................................................ 99

Header 2 ...................................................................................................................................... 101

TPL ............................................................................................................................................... 103

Service 1 ...................................................................................................................................... 104

Service 2 ...................................................................................................................................... 106

NCPDP Pharmacy .............................................................................................................................. 107

Header.......................................................................................................................................... 108

RX ................................................................................................................................................ 110

Partial RX ..................................................................................................................................... 112

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TPL ............................................................................................................................................... 114

Compound .................................................................................................................................... 115

Clinical .......................................................................................................................................... 116

DUR/PPS & Coupon .................................................................................................................... 117

NCPDP Pharmacy Reversal ............................................................................................................... 119

Header.......................................................................................................................................... 120

Service ......................................................................................................................................... 121

Long Term Care Census .................................................................................................................... 122

Census ......................................................................................................................................... 123

Transaction responses ....................................................................................................................... 129

271 Eligibility Response(s) ........................................................................................................... 130

277 Claim Status Response(s) .................................................................................................... 136

278 Prior Authorization Response(s) ........................................................................................... 139

835 Electronic Remittance Advice ............................................................................................... 142

999 Acknowledgement(s)............................................................................................................. 147

Rejected Response Report .......................................................................................................... 148

NCPDP Pharmacy Response(s) .................................................................................................. 150

TA1 Interchange Acknowledgement(s) ........................................................................................ 152

Long Term Care Census Response(s) ........................................................................................ 153

Supplemental Eligibility Response Report(s) ............................................................................... 153

Communication ....................................................................................................................................... 157

Submission ......................................................................................................................................... 159

Sending transactions .................................................................................................................... 159

Receiving files .............................................................................................................................. 160

Web Submission Password Change/Reminder ........................................................................... 161

Resubmission ..................................................................................................................................... 163

View Batch Response and 999s......................................................................................................... 164

View Batch LTC Census Response ................................................................................................... 165

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View Rejected Response Report ........................................................................................................ 166

View Supplemental Eligibility Response ............................................................................................ 167

View Batch 835 ERA Response ......................................................................................................... 168

View Communication Log ................................................................................................................... 169

Lists .......................................................................................................................................................... 170

Building a list in advance .................................................................................................................... 171

Building a list as you enter data .......................................................................................................... 171

Preloaded lists .................................................................................................................................... 171

Lists to build ........................................................................................................................................ 171

Billing/Requesting Provider .......................................................................................................... 172

Beneficiary/Patient/Cardholder/Client .......................................................................................... 174

Attending/Operating Provider ....................................................................................................... 175

Facility/Performing/Referring/Service Provider ............................................................................ 176

NCPDP Billing/Prescribing/NET Destination Provider ................................................................. 178

Facility Name and Address .......................................................................................................... 179

Admit Source ................................................................................................................................ 180

Attachment Type Code ................................................................................................................ 181

Carrier .......................................................................................................................................... 182

Condition Code ............................................................................................................................ 183

Diagnosis ..................................................................................................................................... 184

Modifier......................................................................................................................................... 185

Occurrence ................................................................................................................................... 186

Patient Status ............................................................................................................................... 187

Place of Service ........................................................................................................................... 188

Policy Holder ................................................................................................................................ 189

Procedure/NDC ............................................................................................................................ 191

Revenue ....................................................................................................................................... 192

Type of Bill ................................................................................................................................... 193

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Value Code .................................................................................................................................. 194

Reports ..................................................................................................................................................... 195

Detail Forms reports ........................................................................................................................... 195

Summary Forms reports ..................................................................................................................... 197

List reports .......................................................................................................................................... 199

Tools ......................................................................................................................................................... 200

Archive ................................................................................................................................................ 201

Creating an archive ...................................................................................................................... 202

Restoring an archive .................................................................................................................... 203

Database Recovery ............................................................................................................................ 204

Compact ....................................................................................................................................... 204

Repair ........................................................................................................................................... 204

Unlock .......................................................................................................................................... 205

Change Password .............................................................................................................................. 206

Options ............................................................................................................................................... 207

Batch ............................................................................................................................................ 207

Web .............................................................................................................................................. 209

Retention ...................................................................................................................................... 210

Security .................................................................................................................................................... 211

Security Maintenance ......................................................................................................................... 211

Troubleshooting ...................................................................................................................................... 213

Arkansas Medicaid PES Handbook

01/19/12 7

What is PES? HP‘s Medicaid software, Provider Electronic Solutions (PES), enables health care providers and retail

pharmacies to verify beneficiary eligibility, request prior authorizations, and submit claims electronically.

PES version 2.15 meets the requirements of the Health Insurance Portability and Accountability Act

(HIPAA) for the transmission of electronic transactions.

How is this handbook organized? The Arkansas Medicaid PES Handbook helps new and experienced users load, set up, and use PES

software. It includes the following sections:

Section Content

Getting Started How to load and set up the software, log on, establish a

password, and access the program.

Forms How to create eligibility-verification requests, prior

authorization requests, and claims. Also includes

information about transaction responses.

Communication How to submit transactions, view submission reports, and

view communication log files.

Lists How to build the lists you use regularly.

Reports How to view and print detail or summary reports.

Tools How to archive forms; compact, repair, or unlock the

database; upgrade; change your password; and set up

software options.

Security How to set up and change your password.

Troubleshooting How to solve the most common problems.


04/19/12 8

Getting started You can submit electronic transactions to Arkansas Medicaid only in HIPAA-compliant format. That

means you must have:

Vendor software that meets the requirements of the Health Insurance Portability and

Accountability Act (HIPAA) for the transmission of electronic transactions.

OR

HP Provider Electronic Solutions software, v. 2.15 (available from the Arkansas Medicaid website

at https://www.medicaid.state.ar.us/)

OR

Access to the on-line claim-submission application on the Arkansas Medicaid website

(https://www.medicaid.state.ar.us/).

AND

A submitter registration ID which is available through the Arkansas Medicaid website at

https://www.medicaid.state.ar.us/ or through the EDI Support Desk at (800) 457-4454 in state or

(501) 376-2211 local or out-of-state.

If you have PES software older than version 2.0, it does not meet the requirements of the Health

Insurance Portability and Accountability Act (HIPAA) for the transmission of electronic transactions and

cannot be upgraded. HIPAA-related changes to processing are so extensive that you must replace this

older software (and, consequently, rebuild your database) with the full application of the current version.

If you are using PES 2.09 or greater, you can upgrade to 2.15 by applying the upgrades available on the

Arkansas Medicaid website (https://www.medicaid.state.ar.us/).

NOTE: Always use the upgrade function to keep PES software current. Do not load a new, full

version of the software or your claim data and lists will be deleted.

If you want to upgrade any version of PES prior to version 2.09, contact the EDI Support Center at (800)

457-4454 for assistance. Versions of PES 2.09 or greater do not require that you apply sequential

upgrades, but you may upgrade to PES 2.15 to have the latest version of the software.

Before you upgrade to PES 2.15, create a copy of the ARHIPAA folder and rename it. This serves as a

backup in the event files are lost or damaged during the upgrade process.

PES can be set up on a computer‘s hard disk or on a network. You can choose between Typical and

Workstation (network) setup. You can set up PES on as many computers as needed.

NOTE: PES cannot be used with terminal server solutions.

https://www.medicaid.state.ar.us/





04/19/12 9

System requirements

PES requires the following hardware and software, at minimum:

Windows 2000/XP/Windows 7

Pentium II

64 megabytes RAM

100 megabytes free hard-disk space

800 x 600 resolution

MS Internet Explorer 6.0 or greater

NOTE: HP no longer supports PES installation on Windows 98.

How to download PES

To download HP Provider Electronic Solutions software, version 2.15, follow the instructions on the

Arkansas Medicaid website at https://www.medicaid.state.ar.us/. The file is large, so if you have a slow

connection to the Internet the download may take a long time. If the download doesn't work for you, call

the EDI Support Center at (800) 457-4454.



01/19/12 10

How to load PES on a single computer

From the Web

1. Double-click the downloaded file. The Welcome screen opens.

2. Click Next. The Setup Type screen opens.


01/19/12 11

3. Click Typical. Click Next. The Choose Destination Location screen opens.

4. Click Next to accept the default destination for the software, C:\ARHIPAA. The Choose Database

Destination Location screen opens.

5. Click Next to accept the default destination for the database, C:\ARHIPAA. A graphic shows the

progress of the procedure. You can cancel at any time by clicking the Cancel button.

6. When loading is complete, click Finish.


01/19/12 12

How to load PES on a network

1. Load PES on the server or primary computer, choosing Typical and accepting all defaults.

2. Load PES on each workstation, choosing Workstation and browsing to the location where the

database resides. Only the PES application is loaded on the workstation. The database has

already been loaded on the network server or primary computer and is shared by all workstations.

NOTE: If you need assistance installing PES on your network or resolving transmission problems

when using PES on your network, you will need to contact the technical support representative or

team in your office. EDI does not support network issues.

Opening PES

After you load PES, you can open it in either of these ways:

Double-click the AR HP Provider Electronic Solutions icon on your desktop.

Select Start; select Programs; and click AR HP Provider Electronic Solutions.

Logging on for the first time

1. Open PES. The Logon box opens with User ID filled in: pes-admin. Type HP-pes in the

Password field, and then select OK.


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2. A Password Expired notice opens.

If you choose Cancel, the LogOn ends and PES closes. If you choose OK, a new box opens

allowing you to create a unique password.

3. In the Old Password field, type HP-pes. In the New Password and Rekey New Password

fields, type the password you want to use.

4. From the list in the Question field, select a security question. In Answer and Rekey Answer,

type the answer to the question.

5. Select OK. The system notifies you that your password has been updated.

6. Select OK. The system prompts you to set up your personal options.

To change your password any time after your first log on, see Security Maintenance.

Password Requirements

Passwords are not case-sensitive.

A password can be any combination of alpha, numeric, and special characters.

A password must be 5-10 characters in length.


01/19/12 14

Setting up options

The first time you use PES you must set up the following options: Batch, Web, and Retention. For

instructions on how to set up these options, see the Options section of this manual. In PES, Options can

be found under the Tools menu.

Basic skills

In PES, the keyboard, menus, toolbars, and command buttons are similar to those of other MS Windows

software.

If you are a first-time computer user or have limited experience, take the time to familiarize yourself with

the PES screens and how they work.

Using the keyboard

Some computer users must or prefer to use the keyboard to move around on a screen. The keystrokes

listed in the following table enable you to navigate PES without a mouse device.

Key Action

Tab or Enter Go to the next field.

Shift + Tab Go to the previous field.

Left arrow Move backward within a field.

Right arrow Move forward within a field.

Up arrow Scroll up through a list.

Down arrow Scroll down through a list.

F1 Open online help when the cursor is in a data-entry field.

ESC Exit the help window.

ALT + down

arrow

Show available list choices.

ALT + (shortcut

key)

Each shortcut key is identified on menus by an underlined letter. Press ALT

plus this character to activate the command. Shortcut keys vary from

screen to screen.

Using the mouse

You can use a mouse device to position the cursor on the screen, select an item from a list, or activate a

command.

Click: Slide the mouse to move the cursor into position, and then click the left mouse button.


01/19/12 15

Double-click: To add data to a list, double-click the left mouse button in the field to open a data-entry

window.

Right-click: Use the right mouse button to Cut, Copy, Paste, and Select All.

Using the PES window

Menu bar

The menu bar at the top of the main PES window lists all application functions: File, Forms,

Communication, Lists, Reports, Tools, Security, Window, and Help.

When you select a command, the screen associated with that command opens inside the main PES

window. This screen also has a menu bar.


01/19/12 16

Toolbar

Toolbars provide shortcuts for frequently used menu commands. A toolbar consists of icons that

represent menu commands. Select the icon to activate the command. To see a name or brief description

of the icon, hold the cursor over the icon without clicking. The description displays below the cursor.

Just below the main menu bar is a toolbar with an icon for each type of PES transaction. These icons are

defined in the table below.

270 Eligibility

Request

276 Claim Status

Request

278 Prior

Authorization

Request

837 Dental

837 Institutional

Inpatient

837 Institutional

Inpatient Nursing

Home

837 Institutional

Outpatient

837 Professional

Medicaid

837 Professional

BreastCare

NCPDP Pharmacy NCPDP Pharmacy

Reversal

Long Term Care

Census

Tabs

Related data-entry fields are organized into tabs. To reveal a tab, select the tab name.

List indicator and list

If a button with a down arrow is attached to a field, that means the field contains a list. To display the list,

select the arrow. If the list has scroll bars, use them to view the entire list. If you double-click in a list field,

a data-entry window opens to allow you to add to the list.

Details

Detail rows list line items within a claim or entries in a list.

Status bar

The status bar shows the current state of PES, such as Ready or New Record Added.

Active window

You can open up to three forms, lists, or reports in any combination. On the Window menu, select the

way in which you want to view screens that are displayed simultaneously: cascaded, tiled, or layered.

Command buttons

Command buttons displayed on each screen vary according to the transaction.


01/19/12 17

Using menu commands

Command Action

File On the main menu, exit PES.

On other menus, add, delete, and print.

Edit Cut, copy, or paste data. Add, copy, or delete a service.

View Filter, find, or sort records. View responses and error reports.

Forms Select a form for creating a transaction.

Communication Submit batches of forms and receive batch responses, resubmit batches

of forms and view communication log files.

Lists Add and edit data in reference lists.

Reports Print summary or detail reports with information from forms or reference

lists.

Tools Create and work with archives, maintain the database and change setup

options.

Security Store ID and password.

Window Modify how windows are displayed or move between windows.

Help Obtain help about PES functions, screens, menus and fields using

Contents and Index. Select About to view information about PES, such

as version and copyright.


01/19/12 18

Using command buttons

Command buttons displayed on each screen vary according to the transaction.

Command

button

Action

Add Open a new form that is ready for data entry.

Copy Copy the highlighted form and open the copy for editing.

Delete Delete the current form.

Undo All Reverse all changes to the current form. You can undo only

the changes made since the last time you saved the form.

Save Save the data you have typed in the current form or list.

When you save a form, the data is checked. If required

fields are empty or the data contains errors (for example, if

a Provider ID does not have the correct number of digits),

the errors are listed so you can correct them.

When you save a form, its status is updated in the detail

line to R (Ready to be transmitted).

Find Open a window to search for data within a list.

Print Display eligibility transactions, claim forms and reports in a

report format to be viewed or printed. Also display lists in a

form that can be viewed or printed.

Close Close the form window. If you have made changes to the

current form, PES prompts you to save those changes.


01/19/12 19

Command

button

Action

Add Srv Add a detail line to a transaction; open the data-entry fields

for additional input.

Copy Srv Copy an existing detail line so it can be modified and added

to the transaction.

Delete Srv Remove a detail line that was added in error.

Correcting errors

You cannot save a form that has incorrect or incomplete data. If all of the required data is not included in

a form or list, a list of errors opens when you try to save the form. When you double-click each error

message, the cursor will move to the erroneous field for correction.

NOTE: PES only recognizes errors such as an empty field or alpha characters in a field that

should be all numbers. PES cannot catch content errors, such as an incorrect number of units.

If you cannot complete the form but you want to save the data you have typed so far, select Incomplete.

The transaction is saved with status ―I‖ and cannot be transmitted until it is complete.

Closing PES

Use one of the following options to close PES:

Click the X at the upper-right corner of the screen.

On the File menu, select Exit.

On the toolbar, click the Exit icon.

If you have not saved your work, PES prompts you to save your changes.

Select Yes to save your work and close PES.

Select No to close the active window and keep PES open.

Select Cancel to keep both the active window and PES open.


01/19/12 20

Forms

Arkansas Medicaid transactions can be submitted electronically using forms. The Forms menu includes

the following commands:

270 Eligibility Request

276 Claim Status Request

278 Prior Authorization Request

837 Dental

837 Institutional Inpatient

837 Institutional Nursing Home

837 Institutional Outpatient

837 Professional Medicaid

837 Professional BreastCare

NCPDP Pharmacy

NCPDP Pharmacy Reversal

Long Term Care Census


01/19/12 21

270 Eligibility Request

Use the 270 Eligibility Request form to verify beneficiary eligibility in the Arkansas Medicaid Program.

Verify eligibility every time services are rendered. Eligibility can be checked only for the current day and

up to 365 days into the past. Eligibility cannot be verified for future dates.

The 270 Eligibility Request form has one tab: Header.

To open the 270 Eligibility Request form

On the Forms menu, select 270 Eligibility Request.

OR

On the toolbar of the main screen, click the 270 Eligibility Request icon.


01/19/12 22

Header

To complete the 270 Eligibility Request form, enter data into each of the following fields.

Field name Data

Provider ID Provider‘s NPI or Arkansas Medicaid Provider ID.

If the provider is eligible for an NPI, the NPI must be used here.

If the provider is not eligible for an NPI, the provider‘s Arkansas

Medicaid provider identification number is used.

Select the Provider ID from the list. If the ID number is not in the list,

double-click in the Provider ID field. A data-entry screen opens. Type the

Provider ID. Select Save, and then choose Select.

Beneficiary ID Beneficiary‘s ID.

Select from the list.

OR

Type any of the following sets of data for the beneficiary:

Arkansas Medicaid Beneficiary ID

Date of birth and full name (first/middle initial/last)

Social Security number and date of birth

Social Security number and full name (first/middle initial/last)

If the beneficiary‘s information is in your list, the remaining beneficiary


01/19/12 23

Field name Data

fields are filled automatically.

If you want to add the beneficiary to your list, double-click in the

Beneficiary ID field. A data-entry screen opens. Type the Beneficiary ID.

Select Save, and then choose Select.

Account # Unique patient ID assigned by your facility. If the beneficiary‘s information

is in your list, this field is filled automatically; however, you can change the

data by typing over it.

DOB Beneficiary‘s date of birth. Format: MM/DD/YYYY.

SSN Beneficiary‘s Social Security number.

Last name Beneficiary‘s last name.

First name Beneficiary‘s first name.

MI Beneficiary‘s middle initial.

From DOS Beginning date for which you want to verify eligibility. You can type any

date up to 365 days in the past. Format: MM/DD/YYYY.

To DOS Ending date for which you want to verify eligibility. Format: MM/DD/YYYY.

Do not use a future date.

Trace # Filled automatically by PES.

When you have completed the form,

Select Save to save the transaction

OR

Select Add to save the transaction and open a new form for data entry. You can then use the

Batch Submission feature to verify eligibility for a number of beneficiaries at the same time.

For more information, see Sending transactions.


01/19/12 24

276 Claim Status Request

Use the 276 Claim Status Request form to check the status of a claim that has already been submitted.

The 276 Claim Status Request form has two tabs:

Header 1

Header 2

To open the 276 Claim Status Request form

On the Forms menu, select 276 Eligibility Request.

OR

On the toolbar of the main screen, click the 276 Claim Status Request icon.


01/19/12 25

Header 1

The 276 Claim Status Request form opens with the Header 1 tab on top. To complete Header 1, enter

data into each of the following fields.

Field name Data









If the beneficiary‘s information is in your list, the remaining beneficiary





Last name Filled automatically based on Beneficiary ID.

First name Filled automatically based on Beneficiary ID.


01/19/12 26

Header 2

Select the Header 2 tab and enter data into each of the following fields.

Field name Data

From DOS Beginning date of service. Format: MM/DD/YYYY.

To DOS Ending date of service. Format: MM/DD/YYYY.

Charges Total charges for the services rendered.

Medical Record # Number assigned by you that identifies the beneficiary in your records.

Can contain alpha and numeric characters.

Optional.

Claim # 13-digit ICN of the original claim.

Trace # Filled automatically by the system.


Select Save to save the transaction.

OR

Select Add to save the transaction and open a new form for data entry.


01/19/12 27

278 Prior Authorization Request

Use the 278 Prior Authorization Request form to obtain approval to perform procedures before services

are rendered.

The 278 Prior Authorization Request form has five tabs:

Header 1

Header 2

Service 1

Service 2

Service 3

To open the 278 Prior Authorization Request form

On the Forms menu, select 278 Prior Authorization Request.

OR

On the toolbar of the main screen, click the 278 Prior Authorization Request icon.


01/19/12 28

Header 1

The 278 Prior Authorization Request form opens with the Header 1 tab on top. To complete Header 1,

enter data into each of the following fields.

Field name Data

Requesting

Provider ID

NPI or Arkansas Medicaid Provider ID of the provider requesting prior

authorization.




Select the Provider ID of the provider requesting prior authorization from

the list. If the ID number is not in the list, double-click in the Requesting

Provider ID field. A data-entry screen opens. Type the Provider ID.


PA Reviewing

Department

Department for the type of prior authorization you are requesting.

Select the department from the list,


Select the Beneficiary ID from the list. If the beneficiary‘s information is

already a part of your list, the remaining beneficiary fields are filled

automatically.



01/19/12 29

Field name Data




is in your list, this field is filled automatically; however, you can change

the data by typing over it.

Last Name Beneficiary‘s last name.

First Name Beneficiary‘s first name.

Attachment

Type Code for the title or contents of a document, report, or supporting item for

this claim, if applicable.

Select the code from the list. If the ID code is not in the list, double-click in

the Attachment Type field. A data-entry screen opens. Type the

Attachment Type. Select Save, and then choose Select.

Transmission-

Code

Code that defines the method or format by which reports are to be sent, if

applicable.

Select the code from the list.

Control # Report transmission code you have assigned to the attachment, if

applicable. This code can consist of alpha or numeric characters, or both.

Comment Freeform message clarifying the prior authorization request. Maximum:

80 characters.


01/19/12 30

Header 2


Field name Data

Diagnosis Codes

Primary Primary diagnosis code for the visit.

Select the primary diagnosis from the list. If the code is not in the list,

double-click in the Primary field. A data-entry screen opens. Type the

necessary data. Select Save, and then choose Select.

Admit Diagnosis code for the condition that prompted the beneficiary‘s

admission to the facility.

Select the code from the list. If the code is not in the list, double-click in

the Admit field. A data-entry screen opens. Type the Admit code. Select

Save, and then choose Select.

Other (1

through 6)

An additional diagnosis code related to the visit, if applicable.


the field. A data-entry screen opens. Type the code. Select Save, and

then choose Select.

Related Causes. If the services were made necessary by an accident or employment-related

incident, complete the following fields.

Related Code for the appropriate related cause.


01/19/12 31

Field name Data

Causes (1

through 3)

Incident

Date

If you selected a code for 1, 2, or 3, then the date of the incident is

required. Format: MM/DD/YYYY.

State If the incident was an auto accident, select the code for the state in which

the accident occurred.

Service Provider

ID

NPI or Arkansas Medicaid Provider ID of the provider who will render the

services.




Select the ID from the list. If the ID number is not in the list, double-click

in the Service Provider ID field. A data-entry screen opens. Type the

Service Provider ID. Select Save, and then choose Select.

Place of Service 2-digit code for the place at which service was delivered.

Select the place of service from the list. If the code is not in the list,

double-click in the Place of Service field. A data-entry screen opens.

Type the Place of Service. Select Save, and then choose Select.

Trace # Filled automatically by PES.


01/19/12 32

Service 1

Select the Service 1 tab and enter data into each of the following fields.

Field name Data

Procedure

Qualifier

Code for the type of procedure.

Procedure CPT or HCPCS procedure code.

Select the appropriate code from the list. If the procedure code is not in

the list, double-click in the Procedure field. A data-entry screen opens.

Type the procedure code. Select Save, and then choose Select.

Units Number of days, services, time intervals, or items, depending on the

service provided.

Amount Dollar amount for the requested services.

From DOS Beginning date for the service to be provided.

To DOS Ending date for the service to be provided.

Modifiers

(1 through 4)

Code(s) that further define the procedure code.

Select from the list(s). If the code is not in the list, double-click in a

modifier field. A data-entry screen opens. Type the code. Select Save,

and then choose Select.

Tooth Numbers

1-42

Numbers of teeth for which services are being requested. See the

National Standard Tooth Numbering System of the American Dental

Association.


01/19/12 33

Service 2


Field name Data

Oxygen

Equipment

Types (1 and

2)

Type of equipment prescribed for the delivery of oxygen.

Flow Rate Oxygen flow rate in liters per minute.

Delivery Code for the form of delivery prescribed.

Test

Condition

Code

Code for the conditions under which the beneficiary was tested.

Test

Findings

Codes (1

through 3)

Findings of the oxygen test(s) performed on the beneficiary.

Arterial

Blood Gas

Value of arterial blood gases for the beneficiary.

Daily Use Number of times per day that the beneficiary must use oxygen.

Hourly Use Number of hours per period that the beneficiary must use oxygen.

Portable

System Flow

Oxygen flow rate for a portable oxygen system in liters per minute.


01/19/12 34

Field name Data

Rate

Saturation Value of oxygen saturation.

RT Order Special instructions from the respiratory therapist.

Reason Freeform description of the reason the equipment is needed.


01/19/12 35

Service 3


Field name Data

Home Health

Prognosis Physician‘s prognosis for the beneficiary.

Request

Type

Type of prior authorization request.

Medicare Code showing whether the beneficiary is also a Medicare beneficiary.

SNF Code showing whether the beneficiary is receiving care in a Skilled

Nursing Facility.

Facility

Type

Code for the type of facility from which the beneficiary was discharged.

Surgery

Type

Code for the type of procedure, including HCPCS code, diagnosis code,

tooth code, and NDC.

Surgery

Procedure

Surgical procedure code for the procedure performed.


the Surgery Procedure field. A data-entry screen opens. Type the code.


Dates

Surgery Date on which surgery was performed.

Admission Admission date of beneficiary‘s most recent inpatient stay.


01/19/12 36

Field name Data

Discharge Discharge date of beneficiary‘s most recent inpatient stay.

Original Date on which covered home health services began.

Last Visit Date on which beneficiary was last seen by the physician.

Last

Contact

Date of the home health agency‘s last contact with the physician.

Phys

Order

Date on which the agency received oral orders from the provider to start

care.

Cert From Requested beginning date for services.

Cert To Requested ending date for services.



OR


Batch Submission feature to submit a number of forms at the same time. For more

information, see Sending transactions.


01/19/12 37

837 Dental

Use the 837 Dental form to file claims for dental services.

The 837 Dental form has four tabs:

Header 1

Header 2

TPL (Third Party Liability, added only when applicable)

Services

To open the 837 Dental form

On the Forms menu, select 837 Dental.

OR

On the toolbar of the main screen, click the 837 Dental icon.


01/19/12 38

Header 1

The 837 Dental form opens with the Header 1 tab on top. To complete Header 1, enter data into each of

the following fields.

Field name Data

Provider ID NPI or Arkansas Medicaid Provider ID of the provider.

Select from the list. If the ID number is not in the list, double-click in the

Provider ID field. A data-entry screen opens. Type the Provider ID. Select


Claim Frequency Claim Frequency code.

Select 1 to submit an original claim.

Select 7 to replace a prior claim (indicated by the ICN). Copy the original

claim, change the Claim Frequency to 7, type the 13-digit original ICN,

correct the claim, and save the transaction.

NOTE: To successfully adjust a claim, you cannot alter the provider

ID, beneficiary ID, claim type, or number of details. A claim can

only be adjusted after it is listed as paid on a remittance advice.

It cannot be adjusted during the week that it is originally

submitted.

Select 8 to void (cancel) a prior claim (indicated by the ICN) and have the

payment withheld from future payments.

NOTE: You must complete a voided claim exactly as it was

originally submitted for the cancellation to be successful. You


01/19/12 39

Field name Data

can increase your accuracy when voiding claims by copying the

original claim, changing the Claim Frequency to 8, typing the 13-

digit ICN, and saving the transaction.

Original Claim # 13-digit ICN of the original claim. Use only when Claim Frequency is 7 or

8.


Select the ID from the list. If the beneficiary‘s information is part of your

list, the remaining beneficiary fields are filled automatically.





is part of your list, this field is filled automatically; however, you can

change the data by typing over it.

Last Name Filled automatically, based on Beneficiary ID.

First Name Filled automatically, based on Beneficiary ID.

Attachment

Type Code Code for the title or contents of a document, report, or supporting item for


Transmission-

Code


applicable.




01/19/12 40

Header 2


Field name Data


EPSDT Select Y if the service was rendered as part of the Early and Periodic

Screening, Diagnosis and Treatment Program (EPSDT). If the service

was not part of the EPSDT Program, leave the field blank.

Prior Authorization 10-digit prior authorization number assigned by the Arkansas Medicaid

Dental Care Unit, if applicable.

Orthodontic Treatment

Total Months Total number of months of orthodontic treatment.

Months

Remaining

Number of treatment months remaining.

Related Causes

(1 through 3)

If the services were made necessary by an accident or employment-

related incident, select the code for the appropriate related cause(s).

Incident Date If you selected a Related Cause, then the date of the accident is


Accident State If the incident was an auto accident, select the code for the state in


01/19/12 41

Field name Data

which the accident occurred.

TPL Indicator If the beneficiary has primary insurance coverage for dental services,

select Y from the list; a TPL tab is added to the form and must be

completed. If the beneficiary does not have primary coverage, select N.


01/19/12 42

TPL

Select the TPL tab (if any) and enter data into each of the following fields.

Field name Data

Claim Filing

Indicator Code

Code for the type of other insurance claim being submitted.

Paid Amount Total dollar amount paid by the primary insurance.

Denial Date If Paid Amount is 0, type the date on which the claim was denied by

primary insurance. Format: MM/DD/YYYY.

Policy Holder

Carrier Code Code identifying the insurance carrier—the third party liability (TPL)

carrier code assigned by the Arkansas Medicaid Program.


the Carrier Code field. A data-entry screen opens. Enter a valid carrier

code from the most current list found at www.medicaid.state.ar.us. Select


Carrier

Name

Filled automatically, based on Carrier Code.

Member/

Policy #


https://www.medicaid.state.ar.us/InternetSolution/Provider/codes/carriers.aspx


01/19/12 43

Field name Data

Last Name Filled automatically, based on Carrier Code.

First Name Filled automatically, based on Carrier Code.


01/19/12 44

Services

Select the Services tab and enter data into each of the following fields.

Field name Data

Date of Service Date on which services were provided. Format: MM/DD/YYYY.

Appliance

Placement Date

If an appliance was placed, the date on which it was placed. Format:

MM/DD/YYYY.

Tooth Tooth number, if applicable.

Surfaces

(1 through 5)

Affected tooth surface(s), if applicable.

Oral Cavity

Designation

(1 through 5)

Affected area(s) of the oral cavity, if applicable.

Placement Ind Code indicating whether this placement is initial or replacement. If you

select R, you must complete Prior Placement Date.

Prior Placement

Date

If Placement Ind is R, the prior placement date. Format: MM/DD/YYYY.


service provided.


01/19/12 45

Field name Data


Procedure 5-digit American Dental Association procedure code.

Select the appropriate procedure code from the list. If the procedure code

is not in the list, double-click in the Procedure field. A data-entry screen

opens. Type the procedure code. Select Save, and then choose Select.

Performing

Provider ID

NPI of the provider who rendered the service.

Select the ID from the list. If the ID number is not in the list, double-click

in the Performing Provider ID field. A data-entry screen opens. Type the

ID of the provider. Select Save, and then choose Select.

NOTE: This field is completed only when the billing provider has a

group provider number. If the billing provider number on Header 1

has an entity type of 2 (non-person), then the Performing

Provider ID must have an entity type of 1 (person). The

provider ID used in Header 1 and performing provider ID used in

Services cannot be the same number. If they are the same,

leave the performing provider ID field blank.



OR



01/19/12 46

837 Institutional Inpatient

Use the 837 Institutional Inpatient form to file UB-92 inpatient claims.

The 837 Institutional Inpatient form has eight tabs:

Header 1

Header 2

Header 3

Header 4

Header 5


Crossover (Medicare Crossover, added only when applicable)

Service

To open the 837 Institutional Inpatient form

On the Forms menu, select 837 Institutional Inpatient.

OR

On the toolbar of the main screen, click the 837 Institutional Inpatient icon.


01/19/12 47

Header 1

The 837 Institutional Inpatient claim form opens with the Header 1 tab on top. To complete Header 1,


Field name Data

Provider ID NPI or Arkansas Medicaid Provider ID of the provider.




Type of Bill 3-digit Type of Bill code.

Select from the list. If the code is not in the list, double-click in the Type of

Bill field. A data-entry screen opens. Type the Type of Bill. Select Save,


NOTE: Use the type of bill code ending in 8 to void (cancel) a prior

claim (indicated by the ICN) and have the payment withheld from

future payments.

You must complete a voided claim exactly as it was originally

submitted for the cancellation to be successful. You can increase your

accuracy when voiding claims by copying the original claim, changing

the Type of Bill to 8, typing the 13-digit ICN, and saving the

transaction.

Use 7 as the third digit of the type of bill to replace a prior claim

(indicated by the ICN). Copy the original claim, change the third digit


01/19/12 48

Field name Data

of the type of bill to 7, type the 13-digit original ICN, correct the claim,

and save the transaction.

To successfully adjust a claim, you cannot alter the provider ID,

beneficiary ID, claim type, or number of details. A claim can only be

adjusted after it is listed as paid on a remittance advice. It cannot be

adjusted during the week that it is originally submitted.

Original Claim # If the third digit of the Type of Bill code is 7 or 8, the original 13-digit claim

number assigned by Arkansas Medicaid/HP.


Select the beneficiary ID from the list. If the beneficiary‘s information is


automatically.





is already a part of your list, this field is filled automatically; however, you

can change the data by typing over it.







Optional.

Patient Status 2-digit patient status code.

Select from the list. If the code is not in the list, double-click in the Patient

Status field. A data-entry screen opens. Type the Patient Status. Select


Prior

Authorization

10-digit prior authorization number assigned by Arkansas Medicaid, if

applicable.

Attachment



Transmission

Code


applicable.



01/19/12 49

Field name Data



01/19/12 50

Header 2


Field name Data

Diagnosis Codes


Select from the list. If the code is not in the list, double-click in the Primary

field. A data-entry screen opens. Type the diagnosis code. Select Save,


Other (1

through 8)

Additional diagnosis code related to the visit, if applicable.

Select from the list. If the code is not in the list, double-click in the field. A

data-entry screen opens. Type the diagnosis code. Select Save, and then

choose Select.



Select from the list. If the code is not in the list, double-click in the Admit

field. A data-entry screen opens. Type the code. Select Save, and then

choose Select.

Emergency Diagnosis code describing an injury, poisoning, or adverse effect for

which the service is being billed.

Select from the list. If the code is not in the list, double-click in the


01/19/12 51

Field name Data

Emergency field. A data-entry screen opens. Type the code. Select Save,


Surgical

Codes/Dates

(1 through 6)

Surgical procedure code for the procedure performed during the billing

period.

Select from the list. If the code is not in the list, double-click in a Code

field. A data-entry screen opens. Type the procedure code. Select Save,


Type the date of the procedure in the adjacent field. Format:

MM/DD/YYYY.

Operating

Physician ID

Operating physician‘s NPI or Arkansas Medicaid Provider ID number.

Select from the list. If the NPI is not in the list, double-click in the

Operating Physician ID field. A data-entry screen opens. Type the

Physician ID. Select Save, and then choose Select.


01/19/12 52

Header 3


Field name Data

Occurrence

Codes/Dates

(1 through 8)

Occurrence code defining a significant event relating to this claim. (See

the National Uniform Billing Committee manual.)

Select from the list. If the code is not in the list, double-click in a Code


choose Select.

Type the date of the occurrence in the adjacent field. Format:

MM/DD/YYYY.

PSRO Dates

From First day approved by Provider Statistical and Reimbursement

Organization (PSRO) for a hospital stay. Format: MM/DD/YYYY.

To Last day approved by Provider Statistical and Reimbursement

Organization (PSRO) for a hospital stay. Format: MM/DD/YYYY.

Condition Codes

(1 through 7)

Code for a condition related to this bill that may affect payer processing.

(See the National Uniform Billing Committee manual.)

Select the code from the list. If the code is not in the list, double-click in a

Condition Code field. A data-entry screen opens. Type the necessary

data. Select Save, and then choose Select.


01/19/12 53

Header 4


Field name Data

Value Codes/Amounts (1 through 12)

Code Value codes and corresponding amounts identify data elements

necessary to process this claim as qualified by the payer organization.

The value codes can be found in the National Uniform Billing Committee

(NUBC) manual.

Value codes used for claim processing by Arkansas Medicaid are listed

below:

Value Code ‗80‘ is required with an amount that equals the number of

inpatient covered days.

Value Code ‗81‘ is optional with an amount that equals the number of

inpatient non-covered days. If you enter ‗81‘, the amount for non-covered

days must be greater than ‗0‘.

Amount Value amounts have a decimal followed by two zeroes so by entering

4.00, it will represent 4 days.

Referring Provider

ID

Referring provider‘s NPI or Arkansas Medicaid Provider ID.


double-click in the Referring Provider ID field. A data-entry screen opens.


01/19/12 54

Field name Data

Type the Provider ID. Select Save, and then choose Select.

Attending

Provider ID

Attending provider‘s NPI or Arkansas Medicaid Provider ID.

Select the Provider ID from the list. If the NPI is not in the list, double-click

in the Attending Provider ID field. A data-entry screen opens. Type the

necessary data. Select Save, and then choose Select.


01/19/12 55

Header 5


Field name Data

Admission

Date Date on which the beneficiary was admitted to the facility. Format:

MM/DD/YYYY.

Hour Code for the hour at which the beneficiary was admitted to the facility.

Type Code for the priority of the admission.

Discharge Hour Code for the hour at which the beneficiary was discharged from the

facility.

Admit Source Code for the source of the admission.


the Admit Source field. A data-entry screen opens. Type the code. (See

the National Uniform Billing Committee manual.) Select Save, and then

choose Select.

TPL Indicator If the beneficiary has primary insurance coverage for institutional services,

select Y. A TPL tab is added to the form and must be completed. The field

will default to N (no).

Crossover

Indicator

If the beneficiary has Medicare coverage for institutional services, select

Y. A Crossover tab is added to the form and must be completed. The field

will default to N (no).


01/19/12 56

TPL


Field name Data

Claim Filing

Indicator Code



Denial Date If Paid Amount is 0, date on which the claim was denied by primary

insurance. Format: MM/DD/YYYY.

Policy Holder







Carrier

Name


Member/

Policy #






01/19/12 57

Crossover

Select the Crossover tab (if any) and enter data into each of the following fields.

Field name Data

Claim Filing

Indicator Code

Code for the type of Medicare claim being submitted.

Medicare ICN 13-digit claim number (ICN) assigned by Medicare.

Non Allowed

Amount

Total Medicare non-covered dollar amount.

Medicare Paid

Amount

Dollar amount paid by Medicare.

Adjudication Date Date on which Medicare adjudicated the claim. Format: MM/DD/YYYY.

Blood Deductible

Amount

Total dollar amount paid by Medicare for blood deductible.

Deductible

Amount

Deductible dollar amount that Medicare applied to the claim.

Coinsurance

Amount

Coinsurance dollar amount that Medicare applied to the claim.


01/19/12 58

Service

Select the Service tab and enter data into each of the following fields.

Field name Data

Revenue Code Revenue Code that applies to this inpatient stay.

Select the Revenue Code from the list. If the Revenue Code is not in the

list, double-click in the Revenue Code field. A data-entry screen opens.

Type the Revenue Code. Select Save, and then choose Select.


service provided.

Charges Total charges related to this revenue code.



OR



01/19/12 59

837 Institutional Nursing Home

Use the 837 Institutional Nursing Home form to file Long Term Care (nursing home) claims.

The 837 Institutional Nursing Home form has six tabs:

Header 1

Header 2

Header 3



Service

To open the 837 Institutional Nursing Home form

On the Forms menu, select 837 Institutional Nursing Home.

OR

On the toolbar of the main screen, click the 837 Institutional Nursing Home icon.


01/19/12 60

Header 1

The 837 Institutional Nursing Home claim form opens with the Header 1 tab on top. To complete Header

1, enter data into each of the following fields.

Field name Data

Provider ID NPI or Arkansas Medicaid Provider ID. This ID must be the ID number of

a facility.

Select the ID number from the list. If the ID number is not in the list,




Select Type of Bill code from the list. If the code is not in the list, double-

click in the Type of Bill field. A data-entry screen opens. Type the code.




future payments.





transaction.

Use a 7 as the third digit of the type of bill to replace a prior claim


01/19/12 61

Field name Data


of the type of bill to 7, type the 13-digit original ICN, correct the claim


Original Claim # If the third digit of the Type of Bill code is 7 or 8, original 13-digit claim





automatically.


Beneficiary ID field. A data-entry screen opens. Type Beneficiary ID.







Patient Status Beneficiary‘s patient status code.

Select the patient status code from the list. If the code is not in the list,

double-click in the Patient Status field. A data-entry screen opens. Type

the code. Select Save, and then choose Select.



Optional.

Attachment



Transmission

Code


applicable.




01/19/12 62

Header 2


Field name Data

Admission


MM/DD/YYYY.




Facility Provider

ID

NPI of the facility where the beneficiary resides.

Select the Facility Provider ID from the list. If the ID number is not in the

list, double-click in the Facility Provider ID field. A data-entry screen

opens. Type the Facility Provider ID. Select Save, and then choose

Select.

Required for all Hospice Long Term Care claims.

Facility License # Filled automatically, based on the Facility Provider ID.


01/19/12 63

Header 3


Field name Data

Diagnosis Codes



the Primary field. A data-entry screen opens. Type the diagnosis code.


Other

(1 through 8)

Additional diagnosis code related to the visit if applicable.

Select the additional code from the list. If the code is not in the list,

double-click in the field. A data-entry screen opens. Type the necessary

code. Select Save, and then choose Select.



Select the diagnosis code from the list. If the code is not in the list,

double-click in the Admit field. A data-entry screen opens. Type the code.


TPL Indicator If the beneficiary has primary insurance coverage for nursing home

services, select Y from the list. A TPL tab is added to the form and must

be completed. The field will default to N (no).

Crossover If the beneficiary has Medicare coverage for nursing home services,


01/19/12 64

Field name Data

Indicator select Y from the list. A Crossover tab is added to the form and must be

completed. The field will default to N (no).


01/19/12 65

TPL


Field name Data

Claim Filing

Indicator Code





Policy Holder



Select from the list. If the code is not in the list, double-click in the Carrier

Code field. A data-entry screen opens. Enter a valid carrier code from the

most current list found at www.medicaid.state.ar.us. Select Save, and

then choose Select.

Carrier

Name


Member/

Policy #





01/19/12 66

Field name Data



01/19/12 67

Crossover


Field name Data

Claim Filing

Indicator Code

Code for the type of Medicare claim being submitted.


Non Allowed

Amount


Medicare Paid

Amount



Blood Deductible

Amount


Deductible

Amount


Coinsurance

Amount



01/19/12 68

Service


Field name Data




Select the Revenue Code from the list. If the Revenue Code is not in the

list, double-click in the Revenue Code field. A data-entry screen opens.

Type the code. Select Save, and then choose Select.


service provided.

Charges Total charges related to this revenue code.



OR



01/19/12 69

Copying old claims to submit as new claims

You can use the Edit All feature to create new claims by copying and editing old claims.

1. Copy one or more previously submitted claims that have F (Finalized) status. To copy one claim,

highlight the claim in the list of finalized claims; select Copy; and then select Save. To copy a

batch of claims, see Resubmission section of this manual. Each copied claim now has R (Ready

to transmit) status.

2. Select Edit All. The Edit All data-entry box opens.

3. Complete the fields From DOS, To DOS, and Units, and then select OK.

4. A system message shows the number of claim forms that will be updated. If the number is

correct, select Yes.

5. Review each form that has R status to verify that the billed amount and patient liability are correct

for the number of days billed on the claim. Make any necessary corrections.

6. When all claims are correct, select Close. For information about submitting claims, see

Communication section of this manual.


01/19/12 70

837 Institutional Outpatient

Use the 837 Institutional Outpatient form to file claims for outpatient services.

The 837 Institutional Outpatient form has six tabs:

Header 1

Header 2

Header 3



Service

To open the 837 Institutional Outpatient form

On the Forms menu, select 837 Institutional Outpatient.

OR

On the toolbar of the main screen, click the 837 Institutional Outpatient icon.


01/19/12 71

Header 1

The 837 Institutional Outpatient claim form opens with the Header 1 tab on top. To complete Header 1,


Field name Data

Provider ID Billing provider‘s NPI or Arkansas Medicaid Provider ID.






the Type of Bill field. A data-entry screen opens. Type the Type of Bill




future payments.





transaction.

Use a 7 as the third digit of the type of bill to replace a prior claim


of the type of bill to 7, type the 13-digit original ICN, correct the claim


01/19/12 72

Field name Data







automatically.













Optional.

Prior

Authorization

10-digit prior authorization number assigned by Arkansas Medicaid, if

applicable.

Attachment



Transmission

Code


applicable.




01/19/12 73

Header 2


Field name Data

Diagnosis Codes


Select the diagnosis code from the list. If the code is not in the list,

double-click in the Primary field. A data-entry screen opens. Type the


Other (1

through 8)




then choose Select.

Emergency Diagnosis code describing an injury, poisoning, or adverse effect for

which the service is being billed.


the Emergency field. A data-entry screen opens. Type the code. Select


Attending

Provider ID

Attending provider‘s NPI or Arkansas Medicaid Provider ID number.


double-click in the Attending Provider ID field. A data-entry screen opens.


01/19/12 74

Field name Data

Type the Provider ID. Select Save, and then choose Select.

Referring Provider

ID

Referring provider‘s NPI or Arkansas Medicaid Provider ID number.

Select the Provider ID number from the list. If the ID number is not in the

list, double-click in the Referring Provider ID field. A data-entry screen

opens. Type the Provider ID. Select Save, and then choose Select.

Operating

Physician ID

Operating physician‘s NPI or Arkansas Medicaid Provider ID number.


double-click in the Operating Physician ID field. A data-entry screen


Admission


MM/DD/YYYY.


Discharge Hour Code for the hour at which the beneficiary was discharged from the

facility.


01/19/12 75

Header 3


Field name Data

Condition Codes

Condition Codes

(1 through 7)

Code for a condition. (See the National Uniform Billing Committee

manual.)

Select the code from the list. If the code is not in the list, double-click in a

Condition Code field. A data-entry screen opens. Type the code. Select


Value Codes/Amounts (1 through 12)

Code Code specifying the type of service from a particular industry. (See the

National Uniform Billing Committee manual.)


the Value Code field. A data-entry screen opens. Type the code. Select


Amount Dollar amount corresponding to the value code.

TPL Indicator If the beneficiary has primary insurance coverage for outpatient services,

select Y from the list. A TPL tab is added to the form and must be


Crossover If the beneficiary has Medicare coverage for outpatient services, select Y


01/19/12 76

Field name Data

Indicator from the list. A Crossover tab is added to the form and must be



01/19/12 77

TPL


Field name Data

Claim Filing

Indicator Code





Policy Holder







Carrier Name Filled automatically, based on Carrier Code.

Member/

Policy #






01/19/12 78

Crossover


Field name Data


Allowed Amount Medicare-allowed dollar amount.

Non Allowed

Amount


Medicare Paid

Amount



Blood Deductible

Amount


Deductible

Amount


Coinsurance

Amount



01/19/12 79

Service


Field name Data

Date of Service Date on which services were provided. Format: MM/DD/YYYY.


Select the code from the list. If the Revenue Code is not in the list,

double-click in the Revenue Code field. A data-entry screen opens. Type

the code. Select Save, and then choose Select.

Procedure 5-digit American Dental Association procedure code.

Select the code from the list. If the procedure code is not in the list,

double-click in the Procedure field. A data-entry screen opens. Type the


Modifiers

(1 through 4)


Select the code(s) from the list(s). If the code is not in the list, double-click

in a modifier field. A data-entry screen opens. Type the code. Select



service provided.



01/19/12 80

Field name Data

RX Indicator Select Yes from the list if the beneficiary received medication during the

service. An RX tab is added to the form and must be completed. The field

will default to N (no). Only one RX may be entered per claim detail. A

new detail line must be added on the Service tab in order to enter a

second RX.



OR



01/19/12 81

RX

Select the RX tab (if any) and enter data into each of the following fields.

Field name Data

Drug Identification

NDC 11-digit NDC (National Drug Code) for any prescription drug dispensed in

the office setting to the beneficiary.

Unit of

Measurement

Code for the units of measure in which the prescription drug was

dispensed.

Quantity Number of units dispensed of the prescription drug.

RX/Link # The prescription or link number for the NDC. This field is required when

administering a compound drug. Enter the same link or Rx number on

each detail that represents the compound drug.



OR



01/19/12 82

837 Professional Medicaid

Use the 837 Professional Medicaid form to file claims for medical services.

The 837 Professional Medicaid form has eight tabs:

Header 1

Header 2

Header 3



Service 1

Service 2

NET (Non-Emergency Transportation, added only when applicable)

RX (Prescription Drug, added only when applicable)

To open the 837 Professional Medicaid form

On the Forms menu, select 837 Professional Medicaid.

OR

On the toolbar of the main screen, click the 837 Professional Medicaid icon


01/19/12 83

Header 1

The 837 Professional Medicaid claim form opens with the Header 1 tab on top. To complete Header 1,


Field name Data










NOTE: To successfully adjust a claim, you cannot alter the provider

ID, beneficiary ID, claim type, or number of details. A claim can only

be adjusted after it is listed as paid on a remittance advice. It cannot

be adjusted during the week that it is originally submitted.



NOTE: You must complete a voided claim exactly as it was originally

submitted for the cancellation to be successful. You can increase

your accuracy when voiding claims by copying the original claim,


01/19/12 84

Field name Data

changing the Claim Frequency to 8, typing the 13-digit ICN, and

saving the transaction.




Select the ID from the list. If the beneficiary‘s information is already a part

of your list, the remaining beneficiary fields are filled automatically.


Beneficiary ID field. A data-entry screen opens. Type the ID. Select Save,







Attachment



Transmission

Code


applicable.




01/19/12 85

Header 2


Field name Data

Diagnosis Codes



the Primary field. A data-entry screen opens. Type the code. Select Save,


Other (1

through 7)




then choose Select.

Referring Provider

ID

Referring provider‘s NPI or Arkansas Medicaid Provider ID.


If the provider is not eligible for an NPI, the provider‘s Arkansas Medicaid

provider identification number is used.

Prior Auth 10-digit prior authorization number assigned by Arkansas Medicaid, if

applicable.



01/19/12 86

Field name Data

Hospital Admit

Date

Date on which the beneficiary was admitted to the facility. Format:

MM/DD/YYYY.

Date Last Seen Date on which the beneficiary was last seen.

Onset of Current

Illness Date

Date on which the current illness began.

Facility

Name Name of facility where services were rendered.

NPI NPI or Arkansas Medicaid Provider ID of facility where the services were

rendered.

Address 1 Street address of facility where services were rendered.

Address 2 Second street address line if needed.

City City where services were rendered.

State 2-character postal abbreviation for state.

Zip First 5 digits of zip code are required. Space is available for +4 digits.


01/19/12 87

Header 3


Field name Data

Related Causes. If the services were made necessary by an accident or employment-related

incident, complete the following fields.

1 through 3 Select the code(s) for the appropriate related cause(s).

Incident Date If you selected a code for 1, 2, or 3, then the date of the incident is


Accident

State

Code for the state in which the accident occurred.

Special Program

Code

Code for the special program under which the services were provided.

EPSDT Referral. If the services were rendered as the result of an EPSDT referral, you must

complete the following fields.

Certification

Condition

Indicator

Indicates whether the beneficiary received an EPSDT referral. The field

will default to blank (no).

Condition

Indicator

From the list, select the code for the beneficiary‘s referral status.


01/19/12 88

Field name Data

Therapy Service Category of Care for occupational, physical, and speech therapy claims.

School District School district in which the beneficiary resides.

TPL Indicator If the beneficiary has primary insurance coverage for professional

services, select Y from the list. A TPL tab is added to the form and must

be completed. The field will default to N (no).

Crossover

Indicator

If the beneficiary has Medicare coverage for professional services, select

Y from the list. A Crossover tab is added to the form and must be


NET Indicator If the beneficiary used Non-Emergency Transportation Services in

connection with this claim, select Y from the list. A NET tab is added to

the form and must be completed. The field will default to N (no).


01/19/12 89

TPL


Field name Data

Claim Filing

Indicator Code





Policy Holder







Carrier

Name


Member/

Policy #




01/19/12 90

Field name Data




01/19/12 91

Crossover


Field name Data


Medicare Paid

Amount



Deductible

Amount


Coinsurance

Amount



01/19/12 92

Service 1


Field name Data

Performing

Provider ID

Performing provider‘s NPI or Arkansas Medicaid Provider ID number, if

different than the billing provider‘s ID number.

Select the ID number from the list. If the ID number is not in the list,

double-click in the Performing Provider ID field. A data-entry screen

opens. Type the ID. Select Save, and then choose Select.

If the performing provider‘s ID number is the same as the billing provider‘s

ID number, leave this field blank.



Place of Service Place of service for this detail, if different than the place of service listed in

Header 2.

Select from the list the two-digit code for the place at which service was

delivered. If the code is not in the list, double-click in the Place of Service


choose Select.

If the place of service is the same as that listed in Header 2, leave this

field blank.



01/19/12 93

Field name Data

If the procedure code is not in the list, double-click in the Procedure field.

A data-entry screen opens. Type the procedure code. Select Save, and

then choose Select.

Modifiers

(1 through 4)





Diagnosis Ptr Detail diagnosis number for this service if applicable.

Unit of Measure Unit of measure for this service.


service provided.

Fund Code Provider‘s and beneficiary‘s non-Medicaid fund code assigned by the

Developmental Disabilities Services office. Provider and beneficiary must

be eligible for the same plan code.

Charges Dollar amount charged for services, procedures, or products.


01/19/12 94

Service 2


Field name Data

Emergency

Indicator

Select Yes from the list if the services were rendered due to an

emergency. The field will default to blank (No).

EPSDT Select Yes from the list if the services were rendered as a result of an

EPSDT screening. The field will default to blank (No).

Family Planning Select Yes from the list if the services were rendered in connection with

family planning. The field will default to blank (No).

RX Indicator Select Yes from the list if the beneficiary received medication during the

service. An RX tab is added to the form and must be completed. The field

will default to blank (No). Only one RX may be entered per claim detail. A

new detail line must be added on the Service tab in order to enter a

second RX.


01/19/12 95

NET

Select the NET tab (if any) and enter data into each of the following fields.

Field name Data

Destination

Provider

Destination provider‘s NPI or Arkansas Medicaid Provider ID.

Select the ID from the list. If the NPI is not in the list, double-click in the

Provider ID field. A data-entry screen opens. Type the ID. Select Save,


Request Date Date the NET service was requested by beneficiary. Format:

MMDDYYYY.

Within Service

Region

Indicate whether the service was provided within the region assigned to

the broker.

Others Riding If someone other than the beneficiary was transported by NET provider,

identify that individual. Values:

N = None

E = Escort

I = Inpatient visit by parent/guardian

Transportation Mode of transportation. Values: Bus, Car, Taxi, Van.

Appointment After

Hours

Indicate whether appointment was after business hours.

Lookup Military All time must be reported in military format. If you are not sure how to

express time in military format, click the down-pointing arrow to reveal a


01/19/12 96

Field name Data

Time conversion table.

Original Destination

Scheduled Pick

Up Time

Time scheduled to pick up beneficiary or other rider at original destination.

Use military format.

Actual Pick Up

Time

Time beneficiary or other rider was actually picked up at original

destination. Use military format.

Actual Drop Off

Time

Time beneficiary or other rider was actually dropped off at original

destination. Use military format.

Destination Provider

Appointment Time Time of beneficiary‘s appointment with destination provider. Use military

format.

Actual Drop Off

Time

Time beneficiary or other rider was actually dropped off at destination

provider‘s facility. Use military format.

Actual Pick Up

Time

Time beneficiary or other rider was actually picked up at destination

provider‘s facility. Use military format.



OR



01/19/12 97

RX

Select the RX tab (if any) and enter data into each of the following fields.

Field name Data

Drug Identification

NDC The 11-digit NDC (National Drug Code) for any prescription drug

dispensed in the office setting to the beneficiary.

Unit of

Measure

Code for the units of measure in which the prescription drug was

dispensed.


RX/Link # The prescription or link number for the NDC. This field is required when

administering a compound drug. Enter the same link or Rx number on

each detail that represents the compound drug.



OR



01/19/12 98

837 Professional BreastCare

Use the 837 Professional BreastCare form to file claims for BreastCare services.

The 837 Professional BreastCare form has four tabs:

Header 1

Header 2


Service 1

Service 2

To open the 837 Professional BreastCare form

On the Forms menu, select 837 Professional BreastCare.

OR

On the toolbar of the main screen, click the 837 Professional BreastCare icon.


01/19/12 99

Header 1

The 837 Professional BreastCare claim form opens with the Header 1 tab on top. To complete Header 1,


Field name Data

Provider ID Billing provider‘s NPI or Arkansas Medicaid ID number..

Select the ID from the list. If the ID is not in the list, double-click in the

Provider ID field. A data-entry screen opens. Type the Provider ID. Select







NOTE: To successfully adjust a claim, you cannot alter the

provider ID, client ID, claim type, or number of details. A claim

can only be adjusted after it is listed as paid on a remittance

advice. It cannot be adjusted during the week that it is originally

submitted.



NOTE: You must complete a voided claim exactly as it was

originally submitted for the cancellation to be successful. You

can increase your accuracy when voiding claims by copying the

original claim, changing the Claim Frequency to 8, typing the 13-

digit ICN, and saving the transaction.

Original Claim # If the third digit of the Type of Bill code is 8, original 13-digit claim number


01/19/12 100

Field name Data

assigned by Arkansas Medicaid/HP.

Client ID Client‘s ID.

If the client‘s information is already a part of your list, the remaining client


Select the ID from the list. If you want to add the client to your list, double-

click in the Client ID field. A data-entry screen opens. Type the client ID.


Account # Unique patient ID assigned by your facility. If the client‘s information is

already a part of your list, this field is filled automatically; however, you


Last Name Filled automatically, based on Client ID.

First Name Filled automatically, based on Client ID.

Attachment



Transmission

Code


applicable.




01/19/12 101

Header 2


Field name Data

Diagnosis Codes



the Primary field. A data-entry screen opens. Type the code. Select Save,


Other( 1

through 7)




then choose Select.

Referring Provider

ID

Referring provider‘s NPI or Arkansas Medicaid ID number.


Referring Provider ID field. A data-entry screen opens. Type the ID

number. Select Save, and then choose Select.


Prior

Authorization

10-digit prior authorization number assigned by the Arkansas Department

of Health, if applicable.

TPL Indicator If the client has primary insurance coverage for BreastCare services,

select Y from the list. A TPL tab is added to the form and must be


01/19/12 102

Field name Data


Hospital Admit

Date

Date on which the client was admitted to the facility. Format:

MM/DD/YYYY.

Facility

Name Name of facility where services were rendered.


Address 2 Second street address line, if needed.





01/19/12 103

TPL


Field name Data

Claim Filing

Indicator Code





Policy Holder







Carrier

Name


Member/

Policy #






01/19/12 104

Service 1


Field name Data

Performing

Provider ID

Performing provider‘s ID number, if different than the billing provider‘s ID

number.


double-click in the Performing Provider ID field. A data-entry screen


If the performing provider‘s ID number is the same as the billing provider‘s

ID number, leave this field blank.



Place of Service Place of service for this detail, if different than the place of service listed in

Header 2.

Select the 2-digit code from the list for the place at which service was

delivered. If the code is not in the list, double-click in the Place of Service


choose Select.

If the place of service is the same as that listed in Header 2, leave this

field blank.


Select the code from the list. If the procedure code is not in the list,

double-click in the Procedure field. A data-entry screen opens. Type the


01/19/12 105

Field name Data

procedure code. Select Save, and then choose Select.

Modifiers

(1 through 4)





Diagnosis Ptr Detail diagnosis number for this service, if applicable.


service provided.

Charges Dollar amount charged for services, procedures, or products.


01/19/12 106

Service 2


Field name Data

Result Code Result code for either breast or cervical procedures. See BreastCare

billing manual for code criteria.

Recommendation

Code

Recommendation code for either breast or cervical procedures. See

BreastCare billing manual for code criteria.

Months for STFU If Recommendation Code is 2, number of months required for short term

follow-up.

Pap Smear

Adequacy Code

Code for pap smear. See BreastCare billing manual for criteria.



OR



01/19/12 107

NCPDP Pharmacy

Use the NCPDP (National Council for Prescription Drug Programs) Pharmacy form to file claims for

prescription drugs.

The NCPDP Pharmacy form has seven tabs:

Header

RX

Partial RX


Compound (added only when applicable)

Clinical

DUR/PPS & Coupon

To open the NCPDP Pharmacy form

On the Forms menu, select NCPDP Pharmacy.

OR

On the toolbar of the main screen, click the NCPDP Pharmacy icon.


01/19/12 108

Header

The NCPDP Pharmacy claim form opens with the Header tab on top. To complete the Header, enter data

into each of the following fields.

Field name Data



Provider ID field. A data-entry screen opens. Type the ID. Select Save,


Cardholder ID Beneficiary‘s Arkansas Medicaid ID number.

If the beneficiary‘s information is already a part of your list, the remaining

beneficiary fields are filled automatically.

Select the cardholder ID from the list. If you want to add the beneficiary to

your list, double-click in the Cardholder ID field. A data-entry screen

opens. Type the ID. Select Save, and then choose Select.

Last Name Filled automatically, based on Cardholder ID.

First Name Filled automatically, based on Cardholder ID.

Patient Last Name Enter the last name of the patient receiving the prescription.

Patient First Name Enter the first name of the patient receiving the prescription.

Patient DOB Enter the patient‘s date of birth.


01/19/12 109

Field name Data

Date of Service Current date of service. If service was rendered on a prior date, type the

date. The field will automatically fill with the current date. Format:

MM/DD/YYYY.


Compound Code If the prescription is a compound, select 2 from the list. A Compound tab

is added to the form and must be completed. The field will default to 1 (not

a compound).

Other Coverage

Code

If the beneficiary has other coverage for prescription drugs, select the

applicable code. A TPL tab is added to the form and must be completed.

The field will default to 01 (no other coverage).

Patient Gender Gender of the patient.

Pregnancy

Indicator

Code to indicate whether or not the patient is pregnant.

Required if pregnancy could result in different coverage, pricing, or patient

financial responsibility.

Medicaid Indicator Abbreviation of the state in which the beneficiary has Medicaid coverage.

Required in special situations when State issues instructions. For

example, to identify beneficiaries of another state relocated to AR

because of natural disaster.


01/19/12 110

RX

Select the RX tab and enter data into each of the following fields.

Field name Data

Prescriber ID Prescribing provider‘s NPI or Arkansas Medicaid Provider ID.


Prescription # Identification number of the prescription being filled.

NDC 11-digit NDC (National Drug Code) for any prescription drug dispensed to

the beneficiary.

If the NDC is not in the list, double-click in the NDC field. A data-entry

screen opens. Type the NDCa. Select Save, and then choose Select.


Fill Number Number of times the prescription has been filled. For example: the original

fill is 00, the first refill is 01, the second refill is 02, etc.

Days Supply Number of days‘ supply of the prescription being filled.

Level of Service Level of service provided when administering this prescription to the

beneficiary.

DAW Code If the prescriber instructed ―Dispense As Written,‖ select from the list the

code indicating how those instructions were followed. The field will default


01/19/12 111

Field name Data

to 0 (no product selection indicated).

Ingredient Cost Total cost of all drugs in the detail. For compound drug claims, it is the

system-generated ingredient cost for the metric decimal quantity of the

product included in the compound mixture indicated in Compound

Ingredients—Ingredient Quantity.

Usual &

Customary

Total price being billed from all sources and including all fees, including

ingredient cost and dispensing fee.

Date Prescription

Written

Enter the date the prescription was written/issued.

Basis of Cost

Determination

Enter a code indicating by which method Ingredient Cost submitted was

calculated.


01/19/12 112

Partial RX

Select the Partial RX tab (if any) and enter data into each of the following fields.

Field name Data

Partial Fills

Dispensing

Status

Code showing whether quantity dispensed is a partial fill or completion of

a partial fill. The field will default to blank (not specified).

If Dispensing Status is P, complete the following fields.

Quantity

intended

Metric decimal quantity of medication that would have been dispensed on

original filling if sufficient inventory were available.

Days Supply

Intended

Days‘ supply of medication that would have been dispensed on original

filling if sufficient inventory were available.

If Dispensing Status is C, complete the following fields.

Associated RX

Reference #

Prescription reference number to which the service is related.

Associated RX

Service Date

Date of Associated RX Reference #. Format: MM/DD/YYYY.

Original RX NDC 11-digit NDC (National Drug Code) for the product originally prescribed for

the beneficiary.

If the NDC is not in the list, double-click in the Original RX NDC field. A


01/19/12 113

Field name Data

data-entry screen opens. Type the necessary data. Select Save, and then

choose Select.

Original RX

Quantity

Metric decimal quantity of medication originally prescribed for the

beneficiary.


01/19/12 114

TPL


Field name Data

1) Amount paid Dollar amount paid for the prescription by other insurance carrier billed

before Arkansas Medicaid.

Denial Date If 1) Amount Paid is 0, date on which the claim was denied by primary











01/19/12 115

Compound

Select the Compound tab (if any) and enter data into each of the following fields.

Field name Data

Dosage Form Code for the form of the compound mixture.

Dispensing Unit

Ind

NCPDP standard product billing code for the quantity measurement.

Dosage Route Code for the route of administration of the complete compound mixture.

Process

Compound for

Approved

Ingredients

Code for whether payment is accepted for covered ingredients only. The

field will default to blank (no).

Compound Ingredients

NDC 11-digit NDC (National Drug Code) for the product included in the

compound mixture.

Select the NDC from the list. If the NDC is not in the list, double-click in

the NDC field. A data-entry screen opens. Type the NDC. Select Save,


Ingredient

Quantity

Amount—expressed in metric decimal units—of the product included in

the compound mixture.

Ingredient

Cost

Ingredient cost for the metric decimal quantity of the product included in

the compound mixture (shown in Ingredient Quantity field).


01/19/12 116

Clinical

Select the Clinical tab and enter data into each of the following fields.

Field name Data

Diagnosis Code Diagnosis code related to the prescription, if applicable.


the Diagnosis Code field. A data-entry screen opens. Type the code.


Measurement (1 through 3)

Date Date on which clinical information was collected.

Time Time at which clinical information was collected.

Dimension Code for the clinical domain of Measurement Value.

Unit Code for the unit of measure used with the clinical information.

Value Numeric value associated with Unit.


01/19/12 117

DUR/PPS & Coupon

Select the DUR/PPS & Coupon tab and enter data into each of the following fields.

Field name Data

DUR/PPS

Reason Code that identifies the type of utilization conflict detected. The field will

default to blank (no conflict).

Professional If Reason is not blank, select the code from the list for the pharmacist‘s

intervention. The field will default to blank (not applicable).

Result If Professional is not blank, select the code from the list for the outcome of

the pharmacist‘s intervention.

Coupon

Coupon # Unique serial number assigned to the prescription coupon. If Coupon

Type is not known at the time claim is submitted, do not send Coupon

data. Both Coupon # and Coupon Type must be complete for Coupon to

be processed.

Coupon

Type

Code for type of coupon being used. If Coupon # is not known at the time

claim is submitted, do not send Coupon data. Both Coupon # and Coupon

Type must be complete for Coupon to be processed.

Coupon

Value Amount

Dollar amount of coupon used for this prescription.


01/19/12 118



OR


Batch Submission feature to submit a number of forms at the same time. (For more

information, see Sending transactions.)


01/19/12 119

NCPDP Pharmacy Reversal

Use the NCPDP Pharmacy Reversal form to void a previously submitted pharmacy claim.

The NCPDP Pharmacy Reversal form has two tabs:

Header

Service

To open the NCPDP Pharmacy Reversal form

On the Forms menu, select NCPDP Pharmacy Reversal.

OR

On the toolbar of the main screen, click the NCPDP Pharmacy Reversal icon.


01/19/12 120

Header

The NCPDP Pharmacy Reversal claim form opens with the Header tab on top. To complete the Header,


Field name Data


Select the ID from the list. If the ID number is not in the list, double-click in

the Provider ID field. A data-entry screen opens. Type the ID. Select


Date of Service Date of service. Field will automatically fill with current date. If services

were rendered on a prior date, type the date. Format: MM/DD/YYYY.

Compound Code If the prescription is a compound, select 2 from the list. A Compound tab

is added to the form and must be completed. The field will default to1 (not

a compound).


01/19/12 121

Service


Field name Data

Prescription # Identification number of the prescription being filled.

NDC 11-digit NDC (National Drug Code) for any prescription drug dispensed to

the beneficiary.

Select the NDC from the list. If the NDC is not in the list, double-click in

the NDC field. A data-entry screen opens. Type the NDC. Select Save,




OR


Batch Submission feature to submit a number of forms at the same time. For more

information, see Sending transactions.


01/19/12 122

Long Term Care Census

Use the Long Term Care Census form to submit census data for a long term care facility.

The Long Term Care Census form has one tab: Census.

To open the Long Term Care Census form

On the Forms menu, select LTC Census.

OR

On the toolbar of the main screen, click the LTC Census icon.


01/19/12 123

Census

The Long Term Care Census form opens to the Census tab. To complete Census, enter data into each of

the following fields.

Field name Data




ID. Select Save, and then choose Select.

Census Date Date on which census was taken. Format: MM/YYYY.

Medicaid

SNF Number of Medicaid-eligible patients in the nursing home when the

census was taken whose level of care was Skilled Nursing Facility.

ICF1 Number of Medicaid-eligible patients in the nursing home when the

census was taken whose level of care was Intermediate Care Facility—

Level 1.



Level 2.



Level 3.

ICFMR Number of Medicaid-eligible patients in the nursing home when the


Mentally Retarded.


01/19/12 124

Field name Data

Non

Classified

Number of Medicaid-eligible patients in the nursing home when the

census was taken whose level of care was Non Classified.

Hospice Number of Medicaid-eligible patients in the nursing home when the

census was taken whose level of care was Hospice.

Pending

SNF Number of Medicaid applications pending for patients who were in the

nursing home when the census was taken whose level of care was

Skilled Nursing Facility.

ICF1 Number of Medicaid applications pending for patients who were in the


Intermediate Care Facility—Level 1.







ICFMR Number of Medicaid applications pending for patients who were in the


Intermediate Care Facility—Mentally Retarded.

Non

Classified

Number of Medicaid applications pending for patients who were in the

nursing home when the census was taken whose level of care was Non

Classified.

Hospice Number of Medicaid applications pending for patients who were in the


Hospice.

Non Medicaid

SNF Number of patients in the nursing home who were not eligible for

Medicaid when the census was taken whose level of care was Skilled

Nursing Facility. Include all other non-Medicaid patients. For example,

those who receive benefits from Medicare, VA, or private insurance.

ICF1 Number of patients in the nursing home who were not eligible for

Medicaid when the census was taken whose level of care was

Intermediate Care Facility—Level 1. Include all other non-Medicaid

patients. For example, those who receive benefits from Medicare, VA, or

private insurance.






01/19/12 125

Field name Data

private insurance.





private insurance.

ICFMR Number of patients in the nursing home who were not eligible for


Intermediate Care Facility—Mentally Retarded. Include all other non-

Medicaid patients. For example, such as those who receive benefits from

Medicare, VA, or private insurance.

Non

Classified

Number of patients in the nursing home who were not eligible for

Medicaid when the census was taken whose level of care was Non

Classified. Include all other non-Medicaid patients. For example, those

who receive benefits from Medicare, VA, or private insurance.

Hospice Number of patients in the nursing home who were not eligible for

Medicaid when the census was taken whose level of care was Hospice.

Include all other non-Medicaid patients. For example, those who receive

benefits from Medicare, VA, or private insurance.

Admits

SNF Number of non-Medicaid patients admitted to the nursing home during

the census month whose level of care was Skilled Nursing Facility.

Include Medicaid applicants, pending patients, and all other non-Medicaid

patients. For example, those who have benefits through Medicare, VA,

and private insurance.

ICF1 Number of non-Medicaid patients admitted to the nursing home during

the census month whose level of care was Intermediate Care Facility—

Level 1. Include Medicaid applicants, pending patients, and all other non-

Medicaid patients. For example, those who have benefits through

Medicare, VA, and private insurance.











ICFMR Number of non-Medicaid patients admitted to the nursing home during


Mentally Retarded. Include Medicaid applicants, pending patients, and all


01/19/12 126

Field name Data

other non-Medicaid patients. For example, those who have benefits

through Medicare, VA, and private insurance.

Non

Classified

Number of non-Medicaid patients admitted to the nursing home during

the census month whose level of care was Non Classified. Include

Medicaid applicants, pending patients, and all other non-Medicaid



Hospice Number of non-Medicaid patients admitted to the nursing home during

the census month whose level of care was Hospice. Include Medicaid

applicants, pending patients, and all other non-Medicaid patients. For

example, those who have benefits through Medicare, VA, and private

insurance.

Deaths

SNF Number of non-Medicaid patients who died while in the nursing home

during the census month whose level of care was Skilled Nursing Facility.




ICF1 Number of non-Medicaid patients who died while in the nursing home

during the census month whose level of care was Intermediate Care

Facility—Level 1. Include Medicaid applicants, pending patients, and all













ICFMR Number of non-Medicaid patients who died while in the nursing home


Facility—Mentally Retarded. Include Medicaid applicants, pending

patients, and all other non-Medicaid patients. For example, those who

have benefits through Medicare, VA, and private insurance.

Non

Classified

Number of non-Medicaid patients who died while in the nursing home

during the census month whose level of care was Non Classified. Include




Hospice Number of non-Medicaid patients who died while in the nursing home

during the census month whose level of care was Hospice. Include


01/19/12 127

Field name Data




Transfers

SNF Number of non-Medicaid patients transferred from the nursing home





ICF1 Number of non-Medicaid patients transferred from the nursing home















ICFMR Number of non-Medicaid patients transferred from the nursing home





Non

Classified

Number of non-Medicaid patients transferred from the nursing home





Hospice Number of non-Medicaid patients transferred from the nursing home





Discharges

SNF Number of non-Medicaid patients discharged from the nursing home




01/19/12 128

Field name Data



ICF1 Number of non-Medicaid patients discharged from the nursing home















ICFMR Number of non-Medicaid patients discharged from the nursing home





Non

Classified

Number of non-Medicaid patients discharged from the nursing home





Hospice Number of non-Medicaid patients discharged from the nursing home







OR


Batch Submission feature to submit a number of forms at the same time. (For more

information, see Sending transactions.)


01/19/12 129

Transaction responses

When you submit an electronic transaction to Arkansas Medicaid/HP, the host system notifies you

whether that transaction was accepted or rejected and supplies additional information about the

transaction. PES version 2.15 generates 10 transaction responses:

271 Eligibility Response(s)

Supplemental Eligibility Response Report(s)

277 Claim Status Response(s)

Rejected Response Report(s)

NCPDP Pharmacy Response(s)

Long Term Care Census Response(s)

835 Electronic Remittance Advice(s)

278 Prior Authorization Response(s)

TA1 Interchange Acknowledgement(s)

999 Acknowledgement(s)

NOTE: When viewing transaction responses, PES v2.15 will only display 5010 transaction files.

4010 transactions can only be viewed using PES v2.14 or earlier.


01/19/12 130

271 Eligibility Response(s)

When you submit a 270 Eligibility Request transaction, Arkansas Medicaid returns a 271 Eligibility

Response file, which lists a variety of information about the Arkansas Medicaid beneficiary.

Arkansas Medicaid also returns a Supplemental Eligibility Response.

Batch response

You must download batch responses before you can view them. For more information about download,

see Receiving files.

To view a batch 271 Eligibility Response,

1. From the Communication menu, select View Batch Response and 999s. A list of available

files opens.

2. The first section of the window lists files that have been downloaded. The first eight

characters of the file name represent the Batch Number. The last three characters of the file

name represent the transaction type. After a file is viewed, the last character of the file

extension is changed to V (for example, MC000025_W2380016_357091_5010 _271.fiV).

3. Select the file you want to view. The file displays in the open window.

4. To print a copy of the response, select Print.

Fields

The 271 Eligibility Response includes the following information.

Field name Data

INFORMATION SOURCE


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Field name Data

INFORMATION

SOURCE

Arkansas Medicaid

SOURCE

PRIMARY ID

716007869

VALID REQUEST Displays only when 270 Eligibility Request is rejected. When displayed,

value is N (No).

REJECT REASON Description of error causing 270 Eligibility Request to be rejected for

information source.

FOLLOW-UP Description of action required from provider if 270 Eligibility Request is

rejected for information source.

PROVIDER INFORMATION

PROVIDER LAST

NAME

Last name or organization name on file with Arkansas Medicaid. If

Provider ID is invalid, this field does not display.

PROVIDER FIRST

NAME

First name on file with Arkansas Medicaid. If Provider ID is invalid, this

field does not display.

PROVIDER

NUMBER

Provider ID number as it was keyed on the 270 Eligibility Request.

VALID REQUEST Displays only when the 270 Eligibility Request is rejected. When

displayed, value is N (No).


provider information.


rejected for provider information.

ELIGIBILITY

AUTHORIZATION

#

Confirmation number assigned by Arkansas Medicaid if the beneficiary is

eligible for services on the requested dates of service.

TRACE # Matches Trace # shown on Header 1 of the 270 Eligibility Request.

BENEFICIARY INFORMATION

BENEFICIARY

LAST NAME

Last name on file with Arkansas Medicaid. If the last name on the 270

Eligibility Request is invalid, the invalid name displays.

BENEFICIARY

FIRST NAME

First name on file with Arkansas Medicaid. If the first name on the 270

Eligibility Request is invalid, the invalid name displays.

BENEFICIARY MI Middle initial on file with Arkansas Medicaid. If the middle initial on the

270 Eligibility Request is invalid, the invalid initial displays.

BENEFICIARY ID Beneficiary‘s current Arkansas Medicaid ID number. If the number on the

270 Eligibility Request is invalid, the invalid number displays.


01/19/12 132

Field name Data

BENEFICIARY

ACCOUNT #

Patient account number assigned by you and entered on the 270

Eligibility Request.

BENEFICIARY

DOB

Beneficiary‘s date of birth. Displays only for valid 270 Eligibility Requests.

BENEFICIARY

GENDER

Beneficiary‘s gender. Values:

F = Female

M = Male

U = Unknown

VALID REQUEST Displays only when the 270 Eligibility Request is rejected. When

displayed, value is N (No).


beneficiary information.


rejected for beneficiary information.

ELIGIBILITY INFORMATION

ELIGIBILITY Values: Active or inactive.

PLAN

DESCRIPTION

Beneficiary‘s aid category and description of that category.

ELIGIBILITY

BEGIN DATE

First date on which the beneficiary is eligible for this aid category.

ELIGIBILITY END

DATE

Last date on which the beneficiary is eligible for this aid category.

COUNTY Three-digit county code followed by name of county in which beneficiary

resides.

TPL

INSURANCE TYPE Commercial.

TPL POLICY # Identification number assigned to the policy holder by the third party

insurance carrier.

TPL GROUP # Group number of the third party insurance policy under which the

beneficiary is covered.

TPL MEMBER # Identification number assigned to the policy holder by the third party

insurance carrier.

PLAN NAME Third party insurance carrier‘s name for the plan under which the

beneficiary is covered.

ELIGIBILITY

BEGIN DATE

Date on which the third party insurance policy began.


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Field name Data

ELIGIBILITY END

DATE

Date on which the third party insurance policy ended.

TPL COVERAGE 1 2-digit code for the third party insurance carrier‘s policy coverage and a

description for that code such as, full coverage, accident policy, cancer

policy, or drug only.







TPL COMPANY

CODE

Code assigned by Arkansas Medicaid to the third party insurance carrier.

TPL COMPANY

NAME

Name of the third party insurance carrier.

TPL ADDRESS Address of the third party insurance carrier.

PRIMARY CARE PHYSICIAN

BEGIN DATE Date on which the provider became the PCP for this beneficiary.

END DATE Date on which the provider ceased to be PCP for this beneficiary (last

day of PCP relationship).

MESSAGE Notes whether PCP is required and, if so, whether a PCP has been

assigned. If a PCP is required and assigned, the following fields are filled.

PCP LAST NAME Last name of the assigned PCP.

PCP FIRST NAME First name of the assigned PCP.

PCP SUFFIX The provider‘s credential. For example, MD or RN.

PHONE NUMBER Telephone number of the assigned PCP.

LOCK-IN ID If the beneficiary is locked in to the requesting provider, the provider ID

displays. If the beneficiary is locked in to a different provider, value:

SOMEONE ELSE. If the beneficiary is not locked in to a provider, this

field does not display.

SPEND DOWN

SPEND DOWN

AMOUNT

Amount of beneficiary‘s financial responsibility for medical services.

SPEND DOWN

END DATE

If service is provided on this date, the beneficiary is responsible for

charges up to the amount in the SPEND DOWN AMOUNT field.


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Field name Data

IMMUNIZATIONS

DATE Date of the immunization. Up to 50 immunization records can be

displayed.

NAME Name of immunization delivered on the date indicated. Up to 50

immunization records can be displayed.

IMMUNIZATION

MESSAGE

Arkansas Department of Health contact information.

BENEFIT LIMITS

LAB/XRAY USED Dollar amount of laboratory and/or x-ray benefits used so far for this fiscal

year.

PRESCRIPTIONS

USED

Number of prescriptions used so far for this fiscal year.

OUTPATIENT

VISITS USED

Number of outpatient visits used so far for this fiscal year.

PHYSICIAN VISITS

USED

Number of physician visits used so far for this fiscal year.

INPATIENT VISITS

USED

Number of inpatient visits used so far for this fiscal year.

CONSULTATIONS

USED

Number of consultations used so far for this fiscal year.

VISION

DATE LAST

VISION EXAM

Date of most recent eye examination on the beneficiary‘s Arkansas

Medicaid record.

OPTICAL SCRIPT

DATE

Date of the most recent eyeglass or contact lens prescription on the

beneficiary‘s Arkansas Medicaid record.

CHIROPRACTIC

VISITS

Number of chiropractic visits used so far for this state fiscal year.

WAIVER

ELIGIBILTIY

Begin and end dates of waiver eligibility segment.

ADULT DENTAL

CARE

Dollar amount used so far for this state fiscal year.

ORTHODONTICS Date of orthodontic treatment.

LTC

LIABILITY

AMOUNT

Beneficiary‘s liability (resource) amount.


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Field name Data

LIABILITY BEGIN

DATE

Beneficiary‘s liability amount is applicable beginning on this date.

LIABILITY END

DATE

Beneficiary‘s liability amount is applicable through this date.

LTC BEGIN DATE Start date of beneficiary‘s eligibility for long term care services.

LTC END DATE Ending date of the beneficiary‘s eligibility for long term care services.

LOC BEGIN DATE Start date of the beneficiary‘s level of care (LOC). The beneficiary can

have an LOC of 20 (Skilled Nursing Facility) and change to an LOC of 22

(Intermediate Care Facility Type 1).

LOC END DATE Ending date of the beneficiary‘s level of care (LOC). The beneficiary can

have an LOC of 20 (Skilled Nursing Facility) and change to an LOC of 22

(Intermediate Care Facility Type 1).

LEVEL OF CARE Code for and description of the type of facility at which the beneficiary

resides.

MEDICARE BUYIN

BUY-IN Indicates whether beneficiary has Medicare Part A, Part B, or both.

HIC NUMBER Health insurance claim number assigned by Medicare.

WAIVER

TYPE Code for and description of the waiver services.

AMOUNT Total dollar amount applied to waiver services.

BEGIN DATE First date on which the waiver is effective.

END DATE Last date on which the waiver is effective.


01/19/12 136

277 Claim Status Response(s)

When you submit a 276 Claim Status Request transaction,Arkansas Medicaid returns a 277 Claim Status

Response file. For each claim in the batch that was accepted for processing, the Claim Status Response

lists an ICN.

Each claim that was denied is also listed, and a Rejected Response Report is generated for each denied

claim. See Rejected Response Report for details about why the claims were denied.

The 277 Claim Status Response includes the following information.

Field name Data

BATCH # Number assigned automatically to this batch of claims.

RECEIVED DATE Date on which the transaction was received by the Arkansas Medicaid

system.

INFORMATION SOURCE

PAYER NAME Arkansas Medicaid

PAYER ID 716007869

RECEIVING PROVIDER INFORMATION


01/19/12 137

Field name Data

LAST/ORG NAME If the provider to be paid is an organization, the organization‘s name. If

the provider to be paid is an individual, the last name of that individual.

FIRST NAME If the provider to be paid is an individual, the first name of that individual.

BATCH

SUBMITTER ID

The submitter ID (―MC number‖) of the provider to be paid.

SERVICE PROVIDER INFORMATION

PROVIDER

LAST/ORG NAME

If the provider that performed the service is an organization, the

organization‘s name. If the provider that performed the service is an

individual, the last name of that individual.

PROVIDER FIRST

NAME

If the provider that performed the service is an individual, the first name of

that individual.

PROVIDER ID NPI or Arkansas Medicaid Provider ID of the provider that performed the

service.


BENEFICIARY

DOB

Beneficiary‘s date of birth.

BENEFICIARY

GENDER

Beneficiary‘s gender. Values:

F = Female

M = Male

U = Unknown

BENEFICIARY

LAST NAME

Beneficiary‘s last name.

BENEFICIARY

FIRST NAME

Beneficiary‘s first name.

BENEFICIARY MI Beneficiary‘s middle initial.

BENEFICIARY ID Beneficiary‘s Arkansas Medicaid ID number.

CLAIM LEVEL STATUS INFORMATION

REQUEST

TRACE #

System generated.

CLAIM STATUS

CATEGORY

National code signifying the status of the claim, such as accepted,

rejected, or additional information requested.

CLAIM STATUS National code further defining the claim status category.

PROCESSED

DATE

Date on which the claim was processed.


01/19/12 138

Field name Data

TOTAL BILLED

AMOUNT

Total amount of the claim.

ICN ICN assigned to the claim.

FROM/TO DATE

OF SERVICE

From date and to date of service for the claim.


01/19/12 139

278 Prior Authorization Response(s)

When you request prior authorization for treatment (278 Prior Authorization Request), Arkansas Medicaid

returns a 278 Prior Authorization Response file. The response confirms that your request was accepted

and provides the prior authorization number to be used in submitting claims for the service. If your

request was rejected, the response guides you in correcting the problem so you can resubmit the request.

The 278 Prior Authorization Response includes the following information.

Field name Data

UMO NAME Arkansas Medicaid

UMO IDENTIFIER Code for department reviewing this PA.

UMO CONTACT

NAME

Name of department reviewing this PA.

REQUESTING PROVIDER

PROVIDER LAST Last name of the provider requesting the PA.


01/19/12 140

Field name Data

NAME

PROVIDER FIRST

NAME

First name of the provider requesting the PA.

BATCH

SUBMITTER ID

Submitter ID (―MC number‖) of the provider requesting the PA.

PROVIDER ID NPI or Arkansas Medicaid Provider ID number of the provider requesting

the PA.

BENEFICIARY TRACE INFORMATION

RESPONSE

TRACE #

Unique ID number for this response. Assigned by system.

REQUEST TRACE

#

Unique ID number for this request. Assigned by system.

BENEFICIARY DIAGNOSIS INFORMATION

DIAGNOSIS CODE

1

Diagnosis code for which the PA was requested.


BENEFICIARY

LAST NAME

Last name of the beneficiary for whom the PA was requested.

BENEFICIARY

FIRST NAME

First name of the beneficiary for whom the PA was requested.

BENEFICIARY ID Arkansas Medicaid ID number of the beneficiary for whom the PA was

requested.

BENEFICIARY

ACCOUNT #

Patient account number assigned by the provider requesting the PA.

SERVICE PROVIDER

PROVIDER

LAST/ORG NAME

If the provider performing the service is an organization, the organization

name. If the provider performing the service is an individual, the

provider‘s last name.

PROVIDER FIRST

NAME

If the provider performing the service is an individual, the provider‘s first

name.

PROVIDER ID NPI or Arkansas Medicaid Provider ID number of the provider performing

the service.

SERVICE LEVEL

REQUEST TYPE Type of PA requested. Values:

I = Initial

R = Revision


01/19/12 141

Field name Data

A = Appeal

DECISION Outcome of PA review. Values:

Approved

Denied

Pending

PA NUMBER Prior authorization number to be used on claims for this service.

ISSUE DATE Issue date of current PA.

PA ISSUE DATE Issue date of original PA, if any.

PROCEDURE

CODE

Procedure code to which the PA applies.

FDOS – TDOS From date and to date of service to which the PA applies.

UNITS Number of units of service authorized.

TOOTH NUMBERS If applicable, tooth numbers for which service is authorized.


01/19/12 142

835 Electronic Remittance Advice

If you have signed up to receive electronic remittance advices, you can retrieve an electronic copy of your

RA each Monday. If you want to sign up to receive electronic RAs, call the EDI Help Desk at (501) 376-

2211 for local and out-of-state providers or toll free at (800) 457-4454 for in-state providers.

The 835 Electronic Remittance Advice includes the information outlined in the table below. These fields

are repeated for each claim included in the RA. Only fields that have live data are shown on the RA. If a

field is blank, its label is also omitted from the RA.

Field name Data

BILLING PROVIDER INFORMATION

NAME Payee‘s name.

SSN/EIN Payee‘s Social Security number or Employer Identification Number.

ADDRESS 1 First line of payee‘s address.

ADDRESS 2 Second line of payee‘s address.


01/19/12 143

Field name Data

CITY Payee‘s city.

STATE Payee‘s state.

ZIP Payee‘s zip code.

ID Payee‘s NPI or Arkansas Medicaid Provider ID number.

PAYER INFORMATION

NAME ARKANSAS MEDICAID

ADDRESS 1 500 PRESIDENT CLINTON AVE

ADDRESS 2 SUITE 400

CITY LITTLE ROCK

STATE AR

ZIP 722011745

FINANCIAL INFORMATION

PAID AMOUNT Total amount paid to provider.

EFT INDICATOR Indicates whether payment was by Electronic Funds Transfer.

PAYER DFI ID 051000017

PAYER BANK

ACCOUNT #

73609247

PAYER ID 1716007869

PROVIDER DFI ID Payee‘s Depository Financial Institution ID.

PROVIDER

ACCOUNT #

Payee‘s bank account number.

RA DATE/EFT

DATE

Date on which check was issued or EFT was effective.

INTERNAL

CHECK/EFT#

Trace number for check or EFT transaction.

RECEIVER ID Submitter ID (―MC number‖) of payee.

PRODUCTION

DATE

Date on which RA was produced.

CLAIM PAYMENT INFORMATION

PATIENT

ACCOUNT #

Patient account number assigned by the provider submitting the claim.


01/19/12 144

Field name Data

CLAIM STATUS National code signifying the status of the claim, such as accepted,

rejected, or additional information requested.

BILLED AMOUNT Total amount billed for this claim.

PAID AMOUNT Total amount paid for this claim.

CO-PAY Total amount for which the beneficiary is responsible.

ICN Claim number.

POS Place-of-service code.

CLAIM

FREQUENCY

CODE

Indicates whether this is an original claim or a transaction voiding or

adjusting a previous claim. Values:

1 = Original claim

7 = Adjustment

8 = Void

BENEFICIARY

LAST NAME

Beneficiary‘s last name.

BENEFICIARY

FIRST NAME

Beneficiary‘s first name.

BENEFICIARY

MIDDLE

Beneficiary‘s middle initial.

BENEFICIARY

MEDICAID ID

Beneficiary‘s Arkansas Medicaid ID number.

ATTENDING

PROVIDER

LAST/ORG NAME

The attending provider‘s last name.

PROVIDER FIRST

NAME

The attending provider‘s first name.

PROVIDER ID Attending provider‘s NPI or Arkansas Medicaid Provider ID.

ORIGINAL ICN If this transaction voids a previous claim, the ICN of the original claim.

PRIOR

AUTHORIZATION

#

Prior authorization number assigned to this claim.

MEDICAL

RECORD #

Medical record number assigned by the provider submitting the claim.

FROM DATE OF

SERVICE

Date on which service began for this claim.

TO DATE OF

SERVICE

Date on which service ended for this claim.


01/19/12 145

Field name Data

ALLOWED

AMOUNT

Maximum amount paid by Arkansas Medicaid for this service.

DETAIL PAYMENT INFORMATION

These fields are repeated for each detail included in the claim.

DETAIL [NUMBER]

PAID

PROC/REV/NDC

Procedure code for which this detail was paid.

MODIFIER Procedure modifier for this detail. This field can be repeated up to four

times.

DETAIL BILLED

AMOUNT

Amount billed for this line item.

DETAIL PAID

AMOUNT

Amount paid for this line item.

REVENUE

CODE

National Uniform Billing Committee (NUBC) revenue code for this line

item.

PAID UNITS Number of units paid for this line item.

SUBMITTED

PROC/REV/NDC

Procedure code that was submitted for this detail.

MODIFIER Procedure modifier that was submitted for this detail. This field can be

repeated up to four times.

SUBMITTED

UNITS

Number of units submitted for this line item.

DATE OF

SERVICE

Date of service for this detail.

ADJUSTMENT

REASON

Claim adjustment reason code and description.

ADJUSTMENT

AMOUNT

Amount of adjustment to this detail.

PERFORMING

PROVIDER ID

Performing provider‘s NPI or Arkansas Medicaid Provider ID number.

DETAIL

ALLOWED

AMOUNT

Maximum amount paid by Arkansas Medicaid for this detail.

REMITTANCE

ADVICE CODE

Code and description for remarks related to this detail.

SUMMARY OF PROVIDER ADJUSTMENTS


01/19/12 146

Field name Data

BILLING

PROVIDER ID

Billing provider‘s NPI or Arkansas Medicaid Provider ID number.

FISCAL YEAR-

END

Date on which fiscal year ends.

The following three fields can be repeated up to five times:

ADJUSTMENT

REASON

Code representing the reason an adjustment was necessary.

ADJUSTMENT

IDENTIFIER

Control number for this adjustment.

ADJUSTMENT

AMOUNT

Amount of adjustment.


01/19/12 147

999 Acknowledgement(s)

When you submit a transaction, but something other than the data is invalid (for example the claim

format), the system generates a 999 Acknowledgement. To resolve the issue, print the 999

Acknowledgement and then call the EDI Help Desk at (501) 376-2211 for local and out-of-state providers

or toll free at (800) 457-4454 for in-state providers.


01/19/12 148

Rejected Response Report

If you submit one or more claims in a batch and at least one of the claims is denied, the system generates

a Rejected Response Report for that batch. This report explains the reasons each claim was rejected.

You can use the information from this report to correct your claim in order to resubmit it.

The Rejected Response Report includes the following information.

Field name Data

BATCH ID Number assigned automatically to this batch of claims.

PROVIDER ID NPI or Arkansas Medicaid ID of the provider submitting the claim.


PATIENT

ACCOUNT #

Patient account number assigned by the provider submitting the claim.

FROM DATE OF

SERVICE

From date of service for the claim.

TOTAL BILL

AMOUNT

Total amount of the claim.

NUMBER OF

ERRORS

Count of the errors encountered in the claim.

The body of the report lists each element of a claim that contains an error, the 4-digit code that


01/19/12 149

Field name Data

applies to that error, and a brief description of the error. For example,

HEADER

1071 PRIMARY CARE PHYSICIAN REQUIRED / NONE ASSIGNED


01/19/12 150

NCPDP Pharmacy Response(s)

When you submit an NCPDP Pharmacy transaction, Arkansas Medicaid returns an NCPDP Pharmacy

Response file, which explains the disposition of the claim.

The NCPDP Pharmacy Response file includes the following information.

Field name Data

VERSION/

RELEASE

NUMBER

D.0

TRANSACTION

CODE

B1 – Billing

HEADER

RESPONSE

STATUS

Indicates whether the claim was accepted or rejected.

RESPONSE DATE Date and time at which the response was generated.

PROVIDER ID NPI or Arkansas Medicaid Provider ID of the provider submitting the


01/19/12 151

Field name Data

claim.

DATE OF

SERVICE

Date on which the service was performed.

The following fields are repeated for each detail included in the claim.

CLAIM DETAIL Number of the claim detail.

TRANSACTION

STATUS

Status of the transaction. Values:

P = Paid

R = Rejected

If the detail is paid, the next two fields are ICN and APPROVAL CODE COUNT. If the detail

is rejected, the next two fields are REJECT COUNT and REJECT CODE.

ICN ICN assigned to the claim.

APPROVAL

CODE COUNT

Number of details paid.

REJECT

COUNT

Number of rejection codes generated by this claim

REJECT

CODE

Rejection codes generated by this claim with brief descriptions.

ADDITIONAL

INFORMATION

Notations that further explain the action taken regarding this claim.

HELP DESK

PHONE

(800) 707-3854

PRESCRIPTION # Prescription number associated with this claim.


01/19/12 152

TA1 Interchange Acknowledgement(s)

A ―TA1 response‖ is a variation of an error report for a failed transaction. If your response includes the

characters TA1 within the ―transaction dump‖ area, print the response and then call the EDI Help Desk at

(501) 376-2211 for local and out-of-state providers or toll free at (800) 457-4454 for in-state providers.


04/19/12 153

Long Term Care Census Response(s)

Before you can file Long Term Care claims, you must have an accepted census for the previous month.

Further, the amount Arkansas Medicaid pays in some cases is related to the facility‘s occupancy rate.

When you submit a Long Term Care Census transaction, Arkansas Medicaid returns a Long Term Care

Census Response file, which confirms that your census has been accepted and shows the occupancy

rate; or if it is rejected, it includes information that helps you correct and resubmit your census.

The Long Term Care Census Response file includes the following information.

Field name Data

TRANSACTION

TYPE

LTC CENSUS

Date on which census response was produced.

Time at which census response was produced.

PAY TO

PROVIDER

NUMBER

NPI or Arkansas Medicaid Provider ID number of the entity or individual

that receives payment against this census.

OCCUPANCY

PERCENTAGE

Number of beds occupied in facility divided by number of beds available.

CENSUS DATE Month and year to which the census applies.

All remaining fields in the response file are identical to those in the Long Term Care Census

form.

Supplemental Eligibility Response Report(s)

When you submit a 270 Eligibility Request transaction, Arkansas Medicaid returns two files: a 271

Eligibility Response file and a Supplemental Eligibility Response Report. The supplemental report delivers

additional information about the transaction that cannot be included on the 271 Eligibility Response due to

HIPAA formatting constraints.


04/19/12 154

NOTE: The Supplemental Eligibility Response Report is generated in response only to 270

Eligibility Requests that are submitted in batches or through the Arkansas Medicaid website.

An accepted Supplemental Eligibility Response Report includes the following information. Only fields that

have live data are shown on the report. If a field is blank, its label is omitted from the report, too.

Field name Data

BATCH ID Number assigned automatically to this batch of transactions.

PROVIDER ID NPI or Arkansas Medicaid Provider ID.


PATIENT

ACCOUNT #

Patient account number assigned by the provider submitting the eligibility

request.

FROM DATE OF

SERVICE

Beginning date of service.

BENEFICIARY

NAME

Beneficiary‘s name.

ERROR COUNT Count of the errors encountered in the transaction.

0 = No errors; transaction accepted

ELIGIBILITY

SEGMENT COUNT

Number of eligibility segments listed for this beneficiary. Determined by

the number of Beneficiary ID numbers on record for this beneficiary.

Maximum: 4.


AID CATEGORY Aid category determining the benefits this beneficiary receives.

AID CATEGORY

DESCRIPTION

Description of aid category.


04/19/12 155

Field name Data

ELIGIBILITY

BEGIN DATE

Date on which beneficiary‘s eligibility for services begins.

ELIGIBILITY END

DATE

Date on which beneficiary‘s eligibility for services ends.

COUNTY CODE 2-digit code for beneficiary‘s county of residence.

COUNTY Beneficiary‘s county of residence.

TPL SEGMENT

COUNT

Number of TPL segments included in this report. Maximum: 3. Each

segment has the following 2 fields:

TPL COMPANY

CODE

National Electronic Insurance Clearinghouse (NEIC) code identifying the

insurance carrier.

TPL

SUBSCRIBER

NAME

Name of the insured for the above carrier.

BUYIN

PART A Date on which this beneficiary became eligible for Medicare Part A

benefits.

PART B Date on which this beneficiary became eligible for Medicaid Part B

benefits.

ARKIDS A – EPSDT SCREENINGS

DENTAL Date of beneficiary‘s last EPSDT dental screening.

MEDICAL Date of beneficiary‘s last EPSDT medical screening.

HEARING Date of beneficiary‘s last EPSDT hearing screening.

VISION Date of beneficiary‘s last EPSDT vision screening.

ARKIDS B SCREENINGS

DENTAL Date of beneficiary‘s last ARKids B dental screening.

MEDICAL Date of beneficiary‘s last ARKids B medical screening.

HEARING Date of beneficiary‘s last ARKids B hearing screening.

VISION Date of beneficiary‘s last ARKids B vision screening.

DENTAL

PANORAMIC /

FULL MOUTH

XRAY

Date of beneficiary‘s last panoramic/full mouth x-ray.


04/19/12 156

Field name Data

BITEWINGS Date of beneficiary‘s last bitewing x-rays.

PROPHYLAXIS /

FLOURIDE

Date of beneficiary‘s last prophylaxis/fluoride treatment.

SEALANT –

TOOTH 2

Date sealant was applied to beneficiary's tooth 2.

SEALANT –

TOOTH 3


SEALANT –

TOOTH 14


SEALANT –

TOOTH 15


SEALANT –

TOOTH 18


SEALANT –

TOOTH 19


SEALANT –

TOOTH 30


A rejected Supplemental Eligibility Response Report includes the following information.

Field name Data

BATCH ID Number assigned automatically to this batch of transactions.

PROVIDER ID NPI or Arkansas Medicaid Provider ID.


PATIENT

ACCOUNT #

Patient account number assigned by the provider submitting the eligibility

request.

FROM DATE OF

SERVICE

Beginning date of service.

BENEFICIARY

NAME

Beneficiary‘s name.

ERROR COUNT Count of the errors encountered in the transaction.

The body of the report lists all applicable error codes along with brief descriptions of the errors.

For example,

ERROR CODE 1: Y350 MEDICARE ALLOWED AMOUNT MUST BE NUMERIC

AND GREATER THAN ZERO


01/19/12 157

Communication Use the Communication menu to interact with Arkansas Medicaid via its fiscal agent, HP. Through this

menu you can submit transactions, retrieve responses, and view communication logs.

The following commands are available on the Communication menu:

Submission

Resubmission

View Batch Response and 999s

View Batch LTC Census Response

View Rejected Response Report

View Supplemental Eligibility Response

View Batch 835 ERA Response

View Communication Log


01/19/12 159

Submission

Use the Submission command on the Communication menu to send a batch of Arkansas Medicaid

transactions to HP electronically. A batch consists of one or more requests or claims.

NOTE: You must set up PES options before you can submit transactions. If you have not yet

done so, see Options.

The following instructions describe how to send transactions and receive files separately; however, you

can send files and receive transactions in the same submissions session.

Sending transactions

When you have one or more transactions with R (Ready to transmit) status, you can send a batch:

1. From the Communication menu, select Submission. The Batch Submission window opens.

2. In the Files To Send box, select each type of transaction you want to send. Or select Select

All to send all transactions types with R status.

3. Select Submit. Submitting via internet, PES transmits all transactions with R status. Once

submitted, a message is returned stating ―Submission successful!‖

4. If the transmission fails, you can view the Communication Log files to learn why.

5. Web Server is the submission method default on the initial installation or upgrade of v2.15.


01/19/12 160

Receiving files

To receive files:

1. From the Communication menu, select Submission. The Batch Submission window opens.

2. In the Files To Receive box, select each type of file you want to retrieve. Or select Select All to

receive all files that are waiting to be downloaded.

3. Select Submit. Submitting via internet, PES retrieves all waiting response files. Once submitted,

a message is returned stating Submission successful!

4. If the transmission fails, you can view the Communication Log files to learn why.


01/19/12 161

Web Submission Password Change/Reminder

To change your web submission password:

1. When activating a submission (sending or receiving), the Password Expiration Reminder window

will open beginning 60 days after updating the password.

2. The web submission password expires after 90 days so it is recommended to reset the password

prior to day 90.

3. If the user clicks on the No button, the user will be allowed to continue the submission process,

4. If the user clicks on the Yes button, the Reset Password window opens.

5. Enter the existing password in the Old Password field. Enter the new password in the New

Password field and re-enter the new password in ReKey New Password field to confirm. Click

the OK button.

6. Requirements for creating a secure password are:

Contain minimum 8 characters and maximum of 32 characters

Contain at least 1 uppercase alpha-character

Contain at least 1 lowercase alpha-character

Contain at least 1 number

Contain at least 1 special character (such as $ or !)

Cannot be the same as the user identifier (MC ID)

Cannot contain the same character more than twice

Cannot contain a detectable pattern such as a dictionary word – (with the use of the other type

characters, this shouldn‘t be an issue)

Must differ from your previous 6 passwords

7. If the password is successfully accepted, the window below will open to inform you that your new

password will expire in 90 days.


01/19/12 162

8. The window below will open when activating a submission on day 90 which is the last day you

can reset your password prior to expiration.

9. The window below will appear when your password has expired.


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Resubmission

Depending on the system options you have selected (see Options), as many as 999 batches of forms can

be retained on your computer. Of these, you can resend a single form, several forms, or an entire batch

of forms.

Use the Resubmission command on the Communication menu to resubmit forms when transmission

was interrupted and the transaction did not complete.

To resubmit forms:

1. From the Communication menu, select Resubmission. A list of batches stored on your

computer opens.

2. Select the batch that includes the forms you want to resubmit. A list of forms within that batch

opens. By default, all of the forms already are selected.

3. To resubmit the entire batch, select Resubmit.

OR

To resubmit only some of the forms in the batch, select Deselect All, and then select each

form you want to resubmit.

4. Select Resubmit. The Batch Submission screen opens, and you can proceed as if sending a

regular batch.


01/19/12 164

View Batch Response and 999s

Batch responses and 999 acknowledgements list details about claims that were accepted or rejected by

Arkansas Medicaid. If a claim is rejected, the file includes a list of errors that prevented the transaction

from being accepted.

After you retrieve these files, use View Batch Response and 999s to view them.

1. From the Communication menu, select View Batch Response and 999s. A list of available

files opens.


3. If you want to print the file, select Print.

The first section of the window lists files that have been downloaded. Click the file name to open the file.

The last three characters of the file name represent the transaction type. After a file is viewed, the last

character of the file extension is changed to V (for example, MC900025_W3141064.5010_5010.999.FIV).


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View Batch LTC Census Response

The LTC Census Report verifies the Long Term Care facility‘s occupancy rate and summarizes census

data reported to Arkansas Medicaid.

After you retrieve these files, use View Batch LTC Census Response to view them.

1. From the Communication menu, select View Batch LTC Census Response. A list of

available files opens.





character of the file extension is changed to V (for example, MC900025_W3190969_150701.CEN.FIV).


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View Rejected Response Report

The Rejected Response Report displays details about claims that have been rejected by Arkansas

Medicaid. The report lists the number of errors, the locations of the errors, and the error codes and

descriptions.

Use this report to identify claim errors so you can correct them and resubmit the claims.

After you retrieve these files, use View Rejected Response Report to view them.

1. From the Communication menu, select View Rejected Response Report. A list of available

files opens.





character of the file extension is changed to V (for example, MC900025_W3190969_150765.REJ.FIV).


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View Supplemental Eligibility Response

When you submit a 270 Eligibility Request transaction, Arkansas Medicaid returns two files: a 271

Eligibility Response file and a Supplemental Eligibility Response Report. The supplemental report delivers

additional information about the transaction that cannot be included on the 271 Eligibility Response due to

HIPAA formatting constraints.

NOTE: The Supplemental Eligibility Response Report is generated in response only to 270

Eligibility Requests that are submitted in batches or through the Arkansas Medicaid website.

After you retrieve these files, use View Supplemental Eligibility Response to view them.

1. From the Communication menu, select View Supplemental Eligibility Response. A list of

available files opens.





character of the file extension is changed to V (for example, MC900025_W3180648_141322.ELG.FIV).


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View Batch 835 ERA Response

If you have signed up to receive electronic remittance advices, you can retrieve an electronic copy of your

RA each Monday. If you want to sign up to receive electronic RAs, call the EDI Help Desk at (501) 376-

2211 for local and out-of-state providers or toll free at (800) 457-4454 for in-state providers. Use the RA

to support your internal accounting procedures.

After you retrieve the file, use View Batch 835 ERA Response to view it.

1. From the Communication menu, select View Batch 835 ERA Response. A list of available

files opens.





character of the file extension is changed to V (for example,

MC900025_WEEKLY_19654.835_0_5010.835.FIV).


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View Communication Log

Use the Communication Log to check submission information. It lists files submitted along with file size,

creation date, and creation time. Depending on the system options you have selected (see Options), as

many as 999 communication logs can be saved on your computer.

1. From the Communication menu, select View Communication Log. The Communication Log

window opens, displaying a list of recent submissions.

2. Select the log you want to view.

3. If you want to print the log, select Print.


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Lists

PES uses lists to simplify data entry and help ensure accuracy. Some lists are preloaded; others you

must build. Once you have entered data in a list, you can reuse it from any form that includes that field.

For example, as you create and add to your list of Beneficiary IDs, that data becomes available from any

form that has a Beneficiary ID field.

You can build a list in advance, and you can build and add to lists as you enter data into forms.

NOTE: If you reload PES, you will lose your data. Do not use the full version to load PES 2.15.

Use only the upgrade to avoid losing your data.


01/19/12 171

Building a list in advance

To speed claim submission later, build lists of your most frequently used data in advance. The lists you

must build depend on the types of services you render.

Building a list as you enter data

You can add entries to most lists as needed while you are filling out a form. To add an entry,

1. Double-click in the field containing the list. A data-entry window opens.

2. Fill in the information required by the list.

3. Select Save. The entry is added to the list.

4. Choose Select. The data you just entered is inserted on the form you are filling out.

Preloaded lists

The following lists are preloaded on PES:

Attachment Type

Place of Service

You may edit these lists and delete codes you know are not used in your practice. A shorter list is easier

to use when completing forms.

Lists to build

To open any of the following lists for data entry, select the list from the Lists menu.


01/19/12 172

Billing/Requesting Provider

Field name Data




Medicaid provider identification number is used, and SSN/EIN is

required.

ID Type Values:

Medicaid

NPI

Entity Type Values:

1 – Person (the provider is an individual)

2 – Non-Person (the provider is a group, organization,

or facility)

Last/Org Name If Entity Type is 1 (Person), provider‘s last name. If Entity Type is 2 (Non-

Person), name of the group, organization, or facility.

First Name If Entity Type is 1 (Person), provider‘s first name. If Entity Type is 2 (Non-

Person), this field is unavailable.

Tax ID Type Values:

EIN

SSN

SSN/EIN Provider‘s Social Security Number or Employer Identification Number.

Taxonomy Provider‘s Taxonomy code, used when needed to identify a provider.

Optional.


01/19/12 173

Field name Data

Provider Address

Address Provider‘s street address. DO NOT enter a P.O. box number here.

City Provider‘s city.



Last 4 digits are used when needed to identify a provider.


01/19/12 174

Beneficiary/Patient/Cardholder/Client

Field name Data

Beneficiary ID Beneficiary‘s 10-digit Arkansas Medicaid ID number.

Account # Unique patient ID assigned by your facility.

Beneficiary SSN Beneficiary‘s Social Security Number. Optional.

Last Name Beneficiary‘s last name.

First Name Beneficiary‘s first name.

Beneficiary DOB Beneficiary‘s date of birth. Format: MM/DD/YYYY.

Gender Values:

F – Female

M – Male

U – Unknown

Address

Address Beneficiary‘s street or mailing address.

City Beneficiary‘s city.




01/19/12 175

Attending/Operating Provider

Field name Data

NPI Provider‘s National Provider Identifier.

Last Name Provider‘s last name.

First Name Provider‘s first name.

Attending

Taxonomy

Provider‘s Taxonomy code used when needed to identify a provider.

Optional.


01/19/12 176

Facility/Performing/Referring/Service Provider

Field name Data



If the provider is not eligible for an NPI, the provider‘s Arkansas Medicaid

provider identification number is used, and SSN/EIN is required.

ID Type Values: NPI, Medicaid

Entity Type Values:

1 – Person (the provider is an individual)

2 – Non-Person (the provider is a group,

organization, or facility)

Last/Org Name If Entity Type is 1 (Person), provider‘s last name. If Entity Type is 2 (Non-

Person), name of the group, organization, or facility.

First Name If Entity Type is 1 (Person), provider‘s first name. If Entity Type is 2 (Non-

Person), this field is unavailable.

Taxonomy Provider‘s Taxonomy code, used when needed to identify a provider.

Optional.

Facility License # Required for Hospice Long Term Care claims.

License # of the facility where the beneficiary resides.

Address Provider‘s street address.


State 2-character postal abbreviation for provider‘s state.

Zip First 5 digits of provider‘s zip code are required. Space is available for +4

digits.


01/19/12 177

Field name Data

Tax ID Type Values: EIN, SSN

SSN/EIN Provider‘s Social Security Number or Employer Identification Number.


01/19/12 178

NCPDP Billing/Prescribing/NET Destination Provider

Field name Data

Provider ID Provider‘s NPI.

ID Type Type of provider identification number.

Select ―NPI‖ = National Provider Identifier

Last/Org Name If the provider is an organization, the organization‘s name. If the provider

is an individual, the last name of that individual.

First Name Provider‘s first name.

Provider Address

Address Provider‘s street address.


State 2-character postal abbreviation for provider‘s state.

Zip First 5 digits of provider‘s zip code are required. Space is available for +4

digits.


01/19/12 179

Facility Name and Address

Field name Data

Facility Name Name of facility where services were rendered.

NPI Provider‘s NPI. Required if service was performed at an RSPMI satellite

facility.


Address 2 Second street address line, if needed.





01/19/12 180

Admit Source

Field name Data

Admit Source

Code

National code indicating the source of the admission. (See National

Uniform Billing Committee codes.)

Description Definition of the code.


01/19/12 181

Attachment Type Code

Field name Data

Attachment Type

Code

Code for the title or contents of a document, report, or supporting item for

this claim.



01/19/12 182

Carrier

Field name Data


carrier codes assigned by the Arkansas Medicaid Program.

The only code that is pre-loaded is ‗XXX – Unknown Carrier Code.‘

Users must load valid carrier codes from the most current list found at

www.medicaid.state.ar.us.

Carrier Name Name of the associated insurance carrier.



01/19/12 183

Condition Code

Field name Data

Condition Code Code for condition related to this bill that may affect payer processing.

(See National Uniform Billing Committee codes.)



01/19/12 184

Diagnosis

Field name Data

Diagnosis Code Code for the condition or disease being treated. (See International

Classification of Diseases coding manual).



01/19/12 185

Modifier

Field name Data

Modifier Code Code that can be appended to the end of a procedure code, altering the

service without changing the procedure code.



01/19/12 186

Occurrence

Field name Data

Occurrence Code Code defining a significant event relating to this claim. See the National

Uniform Billing committee (NUBC) manual.



01/19/12 187

Patient Status

Field name Data

Patient Status Code for the beneficiary‘s status on the last day being billed. See the

National Uniform Billing Data Element Specifications for a list of codes.



01/19/12 188

Place of Service

Field name Data

Place of Service

Code

Code for the location at which the service was delivered.



01/19/12 189

Policy Holder

Field name Data








Carrier Name Name of the associated insurance carrier.

Group # Insurance group number. If a group number is not applicable, type the

beneficiary‘s policy number. For Medicare beneficiaries, type the

beneficiary‘s HIC number.

Group Name Group name associated with Group #.

Policy Holder Information

Last Name Last name of insurance policy holder.

First Name First name of insurance policy holder.

Member/

Policy #

Identification number assigned to the policy holder by the insurance

carrier.

Date Of Birth Policy holder‘s date of birth. Format: MM/DD/YYYY.



01/19/12 190

Field name Data

Gender Values:

F – Female

M – Male

U – Unknown

Policy Holder Address Information

Address Policy holder‘s street address.

City Policy holder‘s city.

State Two-character postal abbreviation for state.


Patient Information

Insurance

Type Code

Select a code from the list.

Relationship

to Insured

Select a code from the list.


01/19/12 191

Procedure/NDC

Field name Data

Procedure/NDC Identification code for the service provided or product dispensed.



01/19/12 192

Revenue

Field name Data

Revenue Code Code for the charge for an inpatient or outpatient facility or ancillary

service. Code list is available from the National Uniform Billing

Committee.



01/19/12 193

Type of Bill

Field name Data

Type Of Bill Code identifying the place of service or the type of bill related to the

location at which a health care service was rendered. The first and

second positions are the place of service, and the third position is the

claim frequency.



01/19/12 194

Value Code

Field name Data

Value Code Code for the whole unit, days or monetary nature of the amount

expressed in the value amount field.



01/19/12 195

Reports Use the Reports menu to view or print records of transactions you submit, files you retrieve, and lists you

have created.

Detail Forms reports show all fields for a particular form. Summary Forms reports list groups of forms in

tabular format. List reports show all entries in a list in tabular format.

Detail Forms reports

Detail reports are available for all forms. To generate a detail report:

1. From the Reports menu, select Detail Forms, and then select the form for which you want a

report. The Detail Report window opens, displaying the data entered on the claim or request.

2. If you want to narrow the report, enter data into one of the following fields. If you do not

narrow the report, all forms on the database for that form type are included in the report.


01/19/12 196

Field name Data


Submit Date Date on which the batch of forms was submitted.

Form Status Select one from the list.

3. Select OK. PES generates the report and opens it.

4. If you want a paper copy of the report, select Print.


01/19/12 197

Summary Forms reports

Summary reports are available for all forms. To generate a summary report:

1. From the Reports menu, select Summary Forms, and then select the form for which you

want a report. The Summary Report window opens, displaying a summary of data entered.

2. If you want to narrow the report, enter data into one of the following fields. If you do not

narrow the report, all forms on the database for that form type are included in the report.


01/19/12 198

Field name Data


Submit Date Date on which the batch of forms was submitted.

Form Status Select one from the list.

3. Select OK. PES generates the report and opens it.

4. If you want a paper copy of the report, select Print.


01/19/12 199

List reports

Reports are available for the following lists:

Admit Source

Admission Type

Attachment Type Code

Carrier

Condition Code

Diagnosis

Modifier

Occurrence

Patient Status

Place of Service

Policy Holder

Procedure/NDC

Revenue

Type of Bill

Value Code

To generate a list report:

From the Reports menu, select the name of the list for which you want a report. The Master Listing

window opens to a preview of the report.

If you want a paper copy of the report, select Print.


01/19/12 200

Tools

The Tools menu includes the following commands:

Archive

Database Recovery

Change Password

Options


01/19/12 201

Archive

Use the Archive tool to store older forms in a compressed format. Archiving reduces the size of the

database, so PES works faster while keeping older forms on hand in case you need to refer to them.

PES notifies you when it is time to archive forms, based on the setting you establish in the Retention

option. (See Options.) The default setting is 30 days.

For example, if you accept the default Retention setting for Archive Days, PES reminds you to archive at

30-day intervals. When you create an archive, PES copies any form you submitted more than 30 days

ago to a compressed file, and then it deletes that form from the database. You can copy archives to disks

or CDs to maintain historical files offline.

Forms that are ready to be submitted are not archived; they remain in the database until you submit or

delete them. Forms with I (Incomplete) status that were created before the archive date are deleted are

not saved in the archive file.


01/19/12 202

Creating an archive

To archive forms:

1. If PES is loaded on a network, ask all other users to exit PES.

2. From the Tools menu, select Archive, and then select Create. A system message reminds

you that all other users must exit PES before forms can be archived.

3. Select OK. A system message reminds you that all forms for the archive period with I

(Incomplete) status will be deleted.

4. Select Yes. The Archive Forms dialog box opens.

5. Select each form type that you want to archive. If you want to archive all types, select Select

All.

6. Adjust the age of the forms to be archived if necessary. (This change applies only to this

archiving session. The Retention setting is not changed.)

7. Change the path and/or file name of the archive file to be created, if necessary.

8. Select OK. A system message informs you when the archive is complete.

9. Select OK to close the message. Select OK again to close the Archive Forms window.


01/19/12 203

Restoring an archive

Forms that have been archived and then restored have A (Archived) status. You cannot change these

forms; but you can view them, print them in reports, and copy them as the basis for new transactions.

To move forms from an archive file back into the database:


2. From the Tools menu, select Archive, and then select Restore. The Restore Forms dialog

box opens.

3. Type the path and name of the archive file that you want to restore or use the browse button

to look for the file.

4. Select Next. A list of available form types opens.

5. Select the form type that you want to restore. If the archive contains no forms of that type, a

system message opens. Otherwise, the available forms are listed.

6. Select Next.

7. Select Restore all forms, and then select Finish.

OR

Select Restore only selected forms. Select the forms you want to restore, and then select

Finish.

A system message informs you when the restoration is complete.

8. Select OK to close the message. Select OK again to close the Restore Forms window.


01/19/12 204

Database Recovery

Use the Database Recovery tool to work with EDI help Desk personnel to fix problems with the database.

Database Recovery includes the following commands:

Compact

Repair

Unlock

Compact

Use Compact to make database files smaller and better organized. Each time you delete a form, empty

space is created in the database where that form used to be. The Compact command releases the empty

space to be used again.

To compact the database:


2. From the Tools menu, select Database Recovery, and then select Compact. System

messages show the progress of the procedure.

3. When the procedure is complete, select OK to close the message.

Repair

To repair the database:


2. From the Tools menu, select Database Recovery, and then select Repair. System

messages show the progress of the procedure.

3. When the procedure is complete, select OK to close the message.

4. Compact the database. (See Compact.)


01/19/12 205

Unlock

A system error can cause the database to lock. To unlock the database:

1. From the Tools menu, select Database Recovery, and then select Unlock. A system

message opens, indicating that the database is unlocked.

2. Select OK to close the message.


01/19/12 206

Change Password

PES notifies you when it is time to change your password, based on the setting you establish in the

Retention option. (See Options.) The default setting is 30 days.

You also should change your password any time you think it may have been discovered by an

unauthorized person.

To change your password:

1. On the Tools menu, select Change Password. The Logon window opens with your user ID

pre-filled.

2. In the Old Password field, type your current password. In the New Password and Rekey

New Password fields, type the password you want to use.

3. From the list in the Question field, select a security question. In the Answer and Rekey

Answer fields, type the answer to the question.

4. Select OK. The system notifies you that your password has been updated.

5. Select OK to close the message.

Password Requirements

Passwords are not case-sensitive.

A password can be any combination of alpha, numeric, and special characters.

A password must be 5-10 characters in length.


04/19/12 207

Options

The following options (identified by tabs in the Options window) must be set up the first time you use

PES: Batch, Web, and Retention.

To access the Options window after the initial setup, on the Tools menu, select Options.

Batch

1. Select the Batch tab.

2. In the Web Logon ID field, type your Submitter ID. In the Web Password field, type your

password which will be displayed as asterisks. The Web Logon ID and password are used for

web submission only. This password does not expire.

3. To obtain a WebBBS submitter ID and password for new users or a WebBBS password

which can be used with your existing submitter ID, go to the Arkansas Medicaid website at

https://www.medicaid.state.ar.us and click on PROVIDER, and then click the HIPAA link to

access Submitter Registration. This password expires every 90 days but it is recommended

to change your password prior to day 90 because on day 91, your account will be locked.

When utilizing web batch submission (sending or receiving), you will be prompted to change

your password if you are within 30 days of expiration. A window will appear allowing you to

change the web submission password. If you choose, you may change your web submission

password at https://www.medicaid.state.ar.us/SubmitterUtilities/default.aspx.

4. Select the correct Entity Type Qualifier for the facility.

1 - Person (individual provider)

2 - Non-Person (group or facility)


https://www.medicaid.state.ar.us/SubmitterUtilities/default.aspx


04/19/12 208

5. In the Submitter Last/Org Name field, if the entity type is a person, type the last name of the

provider. If the entity type is a nonperson, type the organization name of the facility or group.

6. In the Submitter First Name field, if the entity type is a person, type the first name of the

provider.

7. In the Contact Phone # field, type the 10-digit telephone number at which the submitter can

be reached.


01/19/12 209

Web

PES uses the information on the Web tab to transmit transactions to Arkansas Medicaid via the internet

1. A check in the “Use Microsoft Internet Explorer Pre-config Settings‖ box indicates use of

Microsoft Internet Explorer configuration settings for connecting to the internet. This box is

checked as a default and is the recommended option for internet batch submission.

2. Select the radio button for LAN or Modem as a Connection Type to indicate how the internet

connection is being established. The selection of one of the radio buttons is required if the ―Use

Microsoft Internet Explorer Pre-config Settings‖ box is unchecked.

3. Check the ―Use Proxy Server‖ box when a proxy server is used to connect to the internet. This

field is optional.

4. Select the Dialup Network from list provided in the drop down box when the connection type is

modem. This field is required if modem was selected as a Connection Type.

5. Enter the address (Universal Resource Locator or URL) of the proxy server in the Proxy

Information Address field. This field is required if ―Use Proxy Server‖ box is checked.

6. In the HTTP Port field, enter the URL (Universal Resource Locator) address of the proxy server.

This field is required if ‗Use Proxy Server‘ box is checked.

7. In the HTTPS Port field, enter the port number of the proxy server used for secure Hyper-text

Transfer Protocol (HTTPS) communication. This field is required if ―Use Proxy Server‖ box is

checked and the HTTP Port is field is blank.

8. In the Proxy Bypass field, enter the address (URLs) that do not use the proxy server.

9. Providers should default to P in the Environmental Ind field. Test environment indicator T is for

HP use only.


01/19/12 210

Retention

Use the Retention tab to confirm default settings or modify settings for the following PES features.

Field name Data

Archive Days Number of days transactions are accumulated before you are prompted

to archive data. If you submit large volumes of claims, archive data every

30 to 60 days. (Default: 30; Maximum: 999)

Max Batch Number of batches retained in the Resubmission option of the

Communication menu. Items on the Batch list are deleted on a first-

in/first-out basis. (Default: 25; Maximum: 999)

Max Verify Number of response files to be stored on your computer. Downloaded

files are deleted on a first-in/first-out basis. (Default: 25; Maximum: 999)

Max Log Number of communication log backup files to be retained. (Default: 25;

Maximum: 999)

Password

Expiration Days

Number of days before password expires.(Default: 30; Maximum: 99)

1. Select OK to save Retention settings.


01/19/12 211

Security

Use the Security menu to assign and delete user IDs and reset passwords. The Security menu has only

one command: Security Maintenance.

Security Maintenance

You can access Security Maintenance only if your authorization level is 3 (Administrator).

To perform security maintenance,

1. On the Security menu, select Security Maintenance. The Security Maintenance window

opens with all data-entry fields blank. Information for all current users is listed at the bottom of

the screen.

2. To change the settings for an existing user, select that user in the list at the bottom of the

screen. The data-entry fields are filled with the user‘s data. Change the user‘s ID, password,

and/or authorization level, and then select Save.

OR

To add a new user, complete the data-entry fields as follows.

Field name Data

User ID Alpha or numeric characters or both.

Password Any combination of alpha, numeric, and special characters. A password


01/19/12 212

Field name Data

must be 5-10 characters in length. When you assign or change a user‘s

password, PES requires that user to change their password at the next

logon.

Authorization

Level

Values:

2 – User (Non-administrator)

3 – Administrator

Level 2 users cannot access Security Maintenance. At least one user

must have authorization level 3.

3. Select Save to save the user record.

OR

Select Add to save the user record and open a new record for data entry.


01/19/12 213

Troubleshooting The following table shows the problems PES users encounter most frequently. They are listed in

alphabetical order by error message.

If the solution described in the table does not work for you, or if you receive an error message that is not

on this list, contact

EDI Help Desk

8:00 a.m. to 4:30 p.m., Monday through Friday

(501) 376-2211 (out-of-state and local calls)

(800) 457-4454 (in-state calls)

Error

code

Error Potential cause(s) Solution(s)

602 Couldn‘t open

transfer file

Internal settings need to be

reset.

Close PES, reopen, login, and try

to submit again.

Too many applications are open. Close other applications and try to

submit again.

The config sys needs to be

modified.

Add a FILESHIGH = 85 line to the

c:\config.sys. (Contact your MIS

department for assistance.)

Error

code


614 Usually a bad

packet type in

Kermit

The transmission was garbled. Close PES, reopen it, log in, and to

submit try again.

1812 SQLSTATE =

1001

[Microsoft]

[ODBC

Microsoft

Access Driver]

Not enough space on temporary

disk.

NOTE: This error usually

occurs when trying to

upgrade to a new version.

Archive claims to free up additional

space on your database.

Cannot find

download path

Workstation cannot find the

database on the network.

Contact the EDI Help Desk for

assistance.

Cannot format

file

User permissions are incorrect. Ask your network administrator to

give you Read, Write, and Modify

permissions on the arhipaa folder

and all subfolders and files.

Cannot open

log file

Too many applications are open. Close other applications and try to

submit again.

Arhipaa\log folder is read-only or

indexing service is not allowed.

Locate the folder where PES is

loaded (for example, C:\arhipaa).


01/19/12 214

Error

code


Right-click the arhipaa\Log folder.

Click Properties.

If Read Only is checked, uncheck

it.

Click the Advanced button.

If ―For fast searching allow

indexing service to index this

folder‖ is not checked, check it.





Error

code


Could not

update the key

sak. The SQL

code was –1

Permissions for the arhipaa

folder are incorrect.

Ask your network administrator to




Arhipaa folder and/or its

subfolders and files are read

only.

Locate the folder where PES is


Right-click the arhipaa folder.

Click Properties.

If ―Read Only‖ is checked, uncheck

it.

Database error

code 9,

SQLSTATE=01

S01

Version of PES being used by

the provider does not

accommodate the length of the

telephone number plus its related

codes.

Upgrade to current version.

Database is

locked by

another user

If PES is loaded on a network,

another user is saving a new or

modified record.

Wait until the other user has

finished saving the record and try

to submit again.

PES did not release a table after

writing the last record.

Unlock the database. See

Database recovery/Unlock.

PES closed abnormally. Contact the EDI Help Desk for

assistance.

Error

Formatting

Eligibility Batch

Option settings are missing or

incorrect.

Correct the Options settings. See

Options.

Too many applications are open. Close all other applications.

File attributes are set to read

only.

Using Windows Explorer, locate

the folder C:\arhipaa\temp.


01/19/12 215

Error

code


Right-click the folder.

Click Properties.


it.

Temp folder in the arhipaa folder

is missing or invalid.



If the folder is missing, create it.

or

If the folder is present, delete and

recreate it.

No files to

download

Responses are not ready to

download.

Try again later. Depending upon

the amount of traffic on the lines, it

can take as long as an hour for

responses to be created and ready

to download.

Unable to send

data. Trying

again…

Communication was interrupted. Try again.

The temp folder in the \arhipaa

folder is missing or invalid.



If the folder is missing, create it.

or

If the folder is present, delete and

recreate it.

Cannot lock the

(claim type)

table

MS Access cannot lock the table,

so the user cannot insert a new

record or modify an existing one.

Close PES, reopen it, and log in

again to reset table status.

Commit failed

while trying to

update the user

table, return

code is -1





Database is

greater than

application

version.

On a network, the PES software

loaded on a workstation is not

the same version as the

database.

Back up the entire arhipaa folder to

the server or LAN. Uninstall PES

from the workstation. Load the

same version being used by the

database, and then copy the

backed-up arnewecs.mdb, Archive

folder, and verify folder.

No files to view Folder is read only. Locate the folder where PES is


Right-click the arhipaa folder.

Click Properties.


it.


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Error

code


When a batch response is

downloaded, it has an extension

of .fil. When you View Batch

Response, an identical file is

created at C:\arhipaa\verify\ with

an extension of .fiv, and the .fil

file is deleted.

If the .fil fails to delete (thus

leaving both files active), the

system cannot determine which

file to use and displays No files

to view.

Open C:\arhipaa\verify\. Locate the

duplicate files, and delete the one

with the .fil extension.

User permissions are incorrect. Contact the EDI Help Desk for

assistance.

PowerBuilder

Application

Execution Error

(R0014)…

…Application

Terminated

Error

The files used by PES to zip and

unzip the setup and upgrade files

have been deleted or corrupted.

Contact the EDI Help Desk for new

copies of the Dynazip files.

Unable to

update the SAK

Anti-virus software loaded on the

provider‘s computer is not

compatible with PES.

Temporarily disable the anti-virus

software while using PES.

Unable to set

the archive

status for the

**** form type

User permissions are incorrect. Contact the EDI Help Desk for

assistance.

System Error –

―Error Number

2. Error text =

Null object

reference…‖

This is an error that appears to

happen at random. Cause is

unknown.

Click OK. PES will close. Open

PES and logon again. Continue as

usual.

Buffer is null This occurs only when a user

who has upgraded to PES 2.07

tries to resubmit a request that

was created in PES 2.06.

Upgrade to the current version.

Arkansas Medicaid Provider Electronic Solutions (PES)...

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