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.
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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
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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.
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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.
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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.
Arkansas Medicaid PES Handbook
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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.
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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.
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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.
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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.
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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.
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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.
Arkansas Medicaid PES Handbook
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.
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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.
Arkansas Medicaid PES Handbook
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.
Arkansas Medicaid PES Handbook
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
Arkansas Medicaid PES Handbook
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.
Arkansas Medicaid PES Handbook
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
Arkansas Medicaid PES Handbook
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.
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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.
Arkansas Medicaid PES Handbook
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
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.
If the beneficiary‘s information is in your list, the remaining beneficiary
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.
Last name Filled automatically based on Beneficiary ID.
First name Filled automatically based on Beneficiary ID.
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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.
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.
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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.
Arkansas Medicaid PES Handbook
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.
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 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.
Select Save, and then choose Select.
PA Reviewing
Department
Department for the type of prior authorization you are requesting.
Select the department from the list,
Beneficiary ID Beneficiary‘s ID.
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.
If you want to add the beneficiary to your list, double-click in the
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01/19/12 29
Field name Data
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.
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.
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01/19/12 30
Header 2
Select the Header 2 tab and enter data into each of the following fields.
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.
Select the code from the list. If the code is not in the list, double-click in
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.
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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.
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 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.
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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.
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Service 2
Select the Service 2 tab and enter data into each of the following fields.
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.
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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.
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Service 3
Select the Service 3 tab and enter data into each of the following fields.
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.
Select the code from the list. If the code is not in the list, double-click in
the Surgery Procedure field. A data-entry screen opens. Type the code.
Select Save, and then choose Select.
Dates
Surgery Date on which surgery was performed.
Admission Admission date of beneficiary‘s most recent inpatient stay.
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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.
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 submit a number of forms at the same time. For more
information, see Sending transactions.
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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.
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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
Save, and then choose 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
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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.
Beneficiary ID Beneficiary‘s ID.
Select the ID from the list. If the beneficiary‘s information is part of your
list, the remaining beneficiary 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 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
this claim, if applicable.
Transmission-
Code
Code that defines the method or format by which reports are to be sent, if
applicable.
Control # Report transmission code you have assigned to the attachment, if
applicable. This code can consist of alpha or numeric characters, or both.
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Header 2
Select the Header 2 tab and enter data into each of the following fields.
Field name Data
Place of Service 2-digit code for the place at which service was delivered.
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
required. Format: MM/DD/YYYY.
Accident State If the incident was an auto accident, select the code for the state in
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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.
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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.
Select the code 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
Filled automatically, based on Carrier Code.
Member/
Policy #
Filled automatically, based on Carrier Code.
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Field name Data
Last Name Filled automatically, based on Carrier Code.
First Name Filled automatically, based on Carrier Code.
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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.
Units Number of days, services, time intervals, or items, depending on the
service provided.
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Field name Data
Charges Total charges for the services rendered.
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.
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.
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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
TPL (Third Party Liability, added only when applicable)
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.
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Header 1
The 837 Institutional Inpatient 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 of the provider.
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.
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,
and then choose Select.
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
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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.
Beneficiary ID Beneficiary‘s ID.
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.
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 already a 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.
From DOS Beginning date of service. Format: MM/DD/YYYY.
To DOS Ending date of service. Format: MM/DD/YYYY.
Medical Record # Number assigned by you that identifies the beneficiary in your records.
Can contain alpha and numeric characters.
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
Save, and then choose Select.
Prior
Authorization
10-digit prior authorization number assigned by Arkansas Medicaid, if
applicable.
Attachment
Type Code Code for the title or contents of a document, report, or supporting item for
this claim, if applicable.
Transmission
Code
Code that defines the method or format by which reports are to be sent, if
applicable.
Control # Report transmission code you have assigned to the attachment, if
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Field name Data
applicable. This code can consist of alpha or numeric characters, or both.
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Header 2
Select the Header 2 tab and enter data into each of the following fields.
Field name Data
Diagnosis Codes
Primary Primary diagnosis code for the visit.
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,
and then choose Select.
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.
Admit Diagnosis code for the condition that prompted the beneficiary‘s
admission to the facility.
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
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Field name Data
Emergency field. A data-entry screen opens. Type the code. Select Save,
and then choose Select.
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,
and then choose Select.
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.
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Header 3
Select the Header 3 tab and enter data into each of the following fields.
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
field. A data-entry screen opens. Type the code. Select Save, and then
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.
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Header 4
Select the Header 4 tab and enter data into each of the following fields.
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.
Select the Provider ID 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.
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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.
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Header 5
Select the Header 5 tab and enter data into each of the following fields.
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.
Select the code from the list. If the code is not in the list, double-click in
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).
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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, 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.
Select the code 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
Filled automatically, based on Carrier Code.
Member/
Policy #
Filled automatically, based on Carrier Code.
Last Name Filled automatically, based on Carrier Code.
First Name Filled automatically, based on Carrier Code.
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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.
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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.
Units Number of days, services, time intervals, or items, depending on the
service provided.
Charges Total charges related to this revenue code.
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.
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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
TPL (Third Party Liability, added only when applicable)
Crossover (Medicare Crossover, added only when applicable)
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.
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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,
double-click in the Provider ID field. A data-entry screen opens. Type the
Provider ID. Select Save, and then choose Select.
Type of Bill 3-digit Type of Bill code.
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.
Select Save, and then choose Select.
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 a 7 as the third digit of the type of bill to replace a prior claim
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Field name Data
(indicated by the ICN). Copy the original claim, change the third digit
of the type of bill to 7, type the 13-digit original ICN, correct the claim
and save the transaction.
Original Claim # If the third digit of the Type of Bill code is 7 or 8, original 13-digit claim
number assigned by Arkansas Medicaid/HP.
Beneficiary ID Beneficiary‘s ID.
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.
If you want to add the beneficiary to your list, double-click in the
Beneficiary ID field. A data-entry screen opens. Type Beneficiary ID.
Select Save, and then choose Select.
Account # Unique patient ID assigned by your facility. If the beneficiary‘s information
is already a 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.
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.
Medical Record # Number assigned by you that identifies the beneficiary in your records.
Can contain alpha and numeric characters.
Optional.
Attachment
Type Code Code for the title or contents of a document, report, or supporting item for
this claim, if applicable.
Transmission
Code
Code that defines the method or format by which reports are to be sent, if
applicable.
Control # Report transmission code you have assigned to the attachment, if
applicable. This code can consist of alpha or numeric characters, or both.
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Header 2
Select the Header 2 tab and enter data into each of the following fields.
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.
From DOS Beginning date of service. Format: MM/DD/YYYY.
To DOS Ending date of service. Format: 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.
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Header 3
Select the Header 3 tab and enter data into each of the following fields.
Field name Data
Diagnosis Codes
Primary Primary diagnosis code for the visit.
Select the 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 diagnosis code.
Select Save, and then choose Select.
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.
Admit Diagnosis code for the condition that prompted the beneficiary‘s
admission to the facility.
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.
Select Save, and then choose Select.
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,
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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).
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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, 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.
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
Filled automatically, based on Carrier Code.
Member/
Policy #
Filled automatically, based on Carrier Code.
Last Name Filled automatically, based on Carrier Code.
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Field name Data
First Name Filled automatically, based on Carrier Code.
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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.
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Service
Select the Service 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.
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 code. Select Save, and then choose Select.
Units Number of days, services, time intervals, or items, depending on the
service provided.
Charges Total charges related to this revenue code.
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.
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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.
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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
TPL (Third Party Liability, added only when applicable)
Crossover (Medicare Crossover, added only when applicable)
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.
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Header 1
The 837 Institutional Outpatient 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 Billing provider‘s NPI or Arkansas Medicaid Provider ID.
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.
Type of Bill 3-digit Type of Bill code.
Select the 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 Type of Bill
code. Select Save, and then choose Select.
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 a 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
of the type of bill to 7, type the 13-digit original ICN, correct the claim
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Field name Data
and save the transaction.
Original Claim # If the third digit of the Type of Bill code is 7 or 8, original 13-digit claim
number assigned by Arkansas Medicaid/HP.
Beneficiary ID Beneficiary‘s ID.
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.
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 already a 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.
From DOS Beginning date of service. Format: MM/DD/YYYY.
To DOS Ending date of service. Format: MM/DD/YYYY.
Medical Record # Number assigned by you that identifies the beneficiary in your records.
Can contain alpha and numeric characters.
Optional.
Prior
Authorization
10-digit prior authorization number assigned by Arkansas Medicaid, if
applicable.
Attachment
Type Code Code for the title or contents of a document, report, or supporting item for
this claim, if applicable.
Transmission
Code
Code that defines the method or format by which reports are to be sent, if
applicable.
Control # Report transmission code you have assigned to the attachment, if
applicable. This code can consist of alpha or numeric characters, or both.
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Header 2
Select the Header 2 tab and enter data into each of the following fields.
Field name Data
Diagnosis Codes
Primary Primary diagnosis code for the visit.
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
code. Select Save, and then choose Select.
Other (1
through 8)
Additional diagnosis code related to the visit, if applicable.
Select the code from the list. If the code is not in the list, double-click in
the 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 the code from the list. If the code is not in the list, double-click in
the Emergency field. A data-entry screen opens. Type the code. Select
Save, and then choose Select.
Attending
Provider ID
Attending provider‘s NPI or Arkansas Medicaid Provider ID number.
Select the Provider ID from the list. If the ID number is not in the list,
double-click in the Attending Provider ID field. A data-entry screen opens.
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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.
Select the Provider ID from the list. If the ID number is not in the list,
double-click in the Operating Physician ID field. A data-entry screen
opens. Type the Provider ID. Select Save, and then choose Select.
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.
Discharge Hour Code for the hour at which the beneficiary was discharged from the
facility.
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Header 3
Select the Header 3 tab and enter data into each of the following fields.
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
Save, and then choose 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.)
Select the code from the list. If the code is not in the list, double-click in
the Value Code field. A data-entry screen opens. Type the code. Select
Save, and then choose 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
completed. The field will default to N (no).
Crossover If the beneficiary has Medicare coverage for outpatient services, select Y
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Field name Data
Indicator from the list. A Crossover tab is added to the form and must be
completed. The field will default to N (no).
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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, 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.
Select the code 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 Filled automatically, based on Carrier Code.
Member/
Policy #
Filled automatically, based on Carrier Code.
Last Name Filled automatically, based on Carrier Code.
First Name Filled automatically, based on Carrier Code.
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Crossover
Select the Crossover tab (if any) and enter data into each of the following fields.
Field name Data
Medicare ICN 13-digit claim number (ICN) assigned by Medicare.
Allowed Amount Medicare-allowed dollar amount.
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.
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Service
Select the Service 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.
Revenue Code Revenue Code that applies to this inpatient stay.
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
code. Select Save, and then choose Select.
Modifiers
(1 through 4)
Code(s) that further define the procedure code.
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
Save, and then choose Select.
Units Number of days, services, time intervals, or items, depending on the
service provided.
Charges Total charges for the services rendered.
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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.
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.
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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.
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.
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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
TPL (Third Party Liability, added only when applicable)
Crossover (Medicare Crossover, added only when applicable)
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
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Header 1
The 837 Professional Medicaid 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 Billing provider‘s NPI or Arkansas Medicaid Provider ID.
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.
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 can increase
your accuracy when voiding claims by copying the original claim,
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Field name Data
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 7 or 8, original 13-digit claim
number assigned by Arkansas Medicaid/HP.
Beneficiary ID Beneficiary‘s ID.
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.
If you want to add the beneficiary to your list, double-click in the
Beneficiary ID field. A data-entry screen opens. Type the ID. Select Save,
and then choose Select.
Account # Unique patient ID assigned by your facility. If the beneficiary‘s information
is already a 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
this claim, if applicable.
Transmission
Code
Code that defines the method or format by which reports are to be sent, if
applicable.
Control # Report transmission code you have assigned to the attachment, if
applicable. This code can consist of alpha or numeric characters, or both.
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Header 2
Select the Header 2 tab and enter data into each of the following fields.
Field name Data
Diagnosis Codes
Primary Primary diagnosis code for the visit.
Select the 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 code. Select Save,
and then choose Select.
Other (1
through 7)
Additional diagnosis code related to the visit, if applicable.
Select the code from the list. If the code is not in the list, double-click in
the field. A data-entry screen opens. Type the code. Select Save, and
then choose Select.
Referring Provider
ID
Referring 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.
Prior Auth 10-digit prior authorization number assigned by Arkansas Medicaid, if
applicable.
Place of Service 2-digit code for the place at which service was delivered.
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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.
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Header 3
Select the Header 3 tab and enter data into each of the following fields.
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
required. Format: MM/DD/YYYY.
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.
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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
completed. The field will default to N (no).
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).
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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, 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.
Select the code 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
Filled automatically, based on Carrier Code.
Member/
Policy #
Filled automatically, based on Carrier Code.
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Field name Data
Last Name Filled automatically, based on Carrier Code.
First Name Filled automatically, based on Carrier Code.
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Crossover
Select the Crossover tab (if any) and enter data into each of the following fields.
Field name Data
Medicare ICN 13-digit claim number (ICN) assigned by Medicare.
Medicare Paid
Amount
Dollar amount paid by Medicare.
Adjudication Date Date on which Medicare adjudicated the claim. Format: MM/DD/YYYY.
Deductible
Amount
Deductible dollar amount that Medicare applied to the claim.
Coinsurance
Amount
Coinsurance dollar amount that Medicare applied to the claim.
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Service 1
Select the Service 1 tab and enter data into each of the following fields.
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.
From DOS Beginning date of service. Format: MM/DD/YYYY.
To DOS Ending date of service. Format: MM/DD/YYYY.
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
field. A data-entry screen opens. Type the code. Select Save, and then
choose Select.
If the place of service is the same as that listed in Header 2, leave this
field blank.
Procedure CPT or HCPCS procedure code.
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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)
Code(s) that further define the procedure code.
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
Save, and then choose Select.
Diagnosis Ptr Detail diagnosis number for this service if applicable.
Unit of Measure Unit of measure for this service.
Units Number of days, services, time intervals, or items, depending on the
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.
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Service 2
Select the Service 2 tab and enter data into each of the following fields.
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.
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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,
and then choose Select.
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
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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.
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.
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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.
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.
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.
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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
TPL (Third Party Liability, added only when applicable)
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.
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Header 1
The 837 Professional BreastCare 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 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
Save, and then choose 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, 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.
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
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
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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
fields are filled automatically.
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.
Select Save, and then choose Select.
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
can change the data by typing over it.
Last Name Filled automatically, based on Client ID.
First Name Filled automatically, based on Client ID.
Attachment
Type Code Code for the title or contents of a document, report, or supporting item for
this claim, if applicable.
Transmission
Code
Code that defines the method or format by which reports are to be sent, if
applicable.
Control # Report transmission code you have assigned to the attachment, if
applicable. This code can consist of alpha or numeric characters, or both.
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Header 2
Select the Header 2 tab and enter data into each of the following fields.
Field name Data
Diagnosis Codes
Primary Primary diagnosis code for the visit.
Select the 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 code. Select Save,
and then choose Select.
Other( 1
through 7)
Additional diagnosis code related to the visit, if applicable.
Select the code from the list. If the code is not in the list, double-click in
the field. A data-entry screen opens. Type the code. Select Save, and
then choose Select.
Referring Provider
ID
Referring 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
Referring Provider ID field. A data-entry screen opens. Type the ID
number. Select Save, and then choose Select.
Place of Service 2-digit code for the place at which service was delivered.
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
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Field name Data
completed. The field will default to N (no).
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 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.
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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, 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.
Select the code 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
Filled automatically, based on Carrier Code.
Member/
Policy #
Filled automatically, based on Carrier Code.
Last Name Filled automatically, based on Carrier Code.
First Name Filled automatically, based on Carrier Code.
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Service 1
Select the Service 1 tab and enter data into each of the following fields.
Field name Data
Performing
Provider ID
Performing provider‘s ID number, if different than the billing provider‘s ID
number.
Select the Provider 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 Provider 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.
From DOS Beginning date of service. Format: MM/DD/YYYY.
To DOS Ending date of service. Format: MM/DD/YYYY.
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
field. A data-entry screen opens. Type the code. Select Save, and then
choose Select.
If the place of service is the same as that listed in Header 2, leave this
field blank.
Procedure CPT or HCPCS 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
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Field name Data
procedure code. Select Save, and then choose Select.
Modifiers
(1 through 4)
Code(s) that further define the procedure code.
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
Save, and then choose Select.
Diagnosis Ptr Detail diagnosis number for this service, if applicable.
Units Number of days, services, time intervals, or items, depending on the
service provided.
Charges Dollar amount charged for services, procedures, or products.
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Service 2
Select the Service 2 tab and enter data into each of the following fields.
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.
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.
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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
TPL (Third Party Liability, added only when applicable)
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.
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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 Billing provider‘s NPI or Arkansas Medicaid Provider ID.
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 ID. Select Save,
and then choose Select.
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.
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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.
Place of Service 2-digit code for the place at which service was delivered.
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.
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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.
If the provider is eligible for an NPI, the NPI must be used here.
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.
Quantity Number of units dispensed of the prescription drug.
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
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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.
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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
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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.
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TPL
Select the TPL tab (if any) and enter data into each of the following fields.
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
insurance. Format: MM/DD/YYYY.
2) Amount paid Dollar amount paid for the prescription by other insurance carrier billed
before Arkansas Medicaid.
Denial Date If 2) Amount Paid is 0, date on which the claim was denied by primary
insurance. Format: MM/DD/YYYY.
3) Amount paid Dollar amount paid for the prescription by other insurance carrier billed
before Arkansas Medicaid.
Denial Date If 3) Amount Paid is 0, date on which the claim was denied by primary
insurance. Format: MM/DD/YYYY.
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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,
and then choose Select.
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).
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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.
Select the code from the list. If the code is not in the list, double-click in
the Diagnosis Code field. A data-entry screen opens. Type the code.
Select Save, and then choose Select.
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.
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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.
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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 submit a number of forms at the same time. (For more
information, see Sending transactions.)
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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.
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Header
The NCPDP Pharmacy Reversal 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 Billing provider‘s NPI or Arkansas Medicaid Provider ID.
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
Save, and then choose 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).
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Service
Select the Service tab and enter data into each of the following fields.
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,
and then choose Select.
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 submit a number of forms at the same time. For more
information, see Sending transactions.
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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.
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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
Provider ID Billing provider‘s NPI or Arkansas Medicaid Provider ID.
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
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.
ICF2 Number of Medicaid-eligible patients in the nursing home when the
census was taken whose level of care was Intermediate Care Facility—
Level 2.
ICF3 Number of Medicaid-eligible patients in the nursing home when the
census was taken whose level of care was Intermediate Care Facility—
Level 3.
ICFMR Number of Medicaid-eligible patients in the nursing home when the
census was taken whose level of care was Intermediate Care Facility—
Mentally Retarded.
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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
nursing home when the census was taken whose level of care was
Intermediate Care Facility—Level 1.
ICF2 Number of Medicaid applications pending for patients who were in the
nursing home when the census was taken whose level of care was
Intermediate Care Facility—Level 2.
ICF3 Number of Medicaid applications pending for patients who were in the
nursing home when the census was taken whose level of care was
Intermediate Care Facility—Level 3.
ICFMR Number of Medicaid applications pending for patients who were in the
nursing home when the census was taken whose level of care was
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
nursing home when the census was taken whose level of care was
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.
ICF2 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 2. Include all other non-Medicaid
patients. For example, those who receive benefits from Medicare, VA, or
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Field name Data
private insurance.
ICF3 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 3. Include all other non-Medicaid
patients. For example, those who receive benefits from Medicare, VA, or
private insurance.
ICFMR 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—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.
ICF2 Number of non-Medicaid patients admitted to the nursing home during
the census month whose level of care was Intermediate Care Facility—
Level 2. Include Medicaid applicants, pending patients, and all other non-
Medicaid patients. For example, those who have benefits through
Medicare, VA, and private insurance.
ICF3 Number of non-Medicaid patients admitted to the nursing home during
the census month whose level of care was Intermediate Care Facility—
Level 3. 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
the census month whose level of care was Intermediate Care Facility—
Mentally Retarded. Include Medicaid applicants, pending patients, and all
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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
patients. For example, those who have benefits through Medicare, VA,
and private insurance.
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.
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 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
other non-Medicaid patients. For example, those who have benefits
through Medicare, VA, and private insurance.
ICF2 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 2. Include Medicaid applicants, pending patients, and all
other non-Medicaid patients. For example, those who have benefits
through Medicare, VA, and private insurance.
ICF3 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 3. 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 who died while in the nursing home
during the census month whose level of care was Intermediate Care
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
Medicaid applicants, pending patients, and all other non-Medicaid
patients. For example, those who have benefits through Medicare, VA,
and private insurance.
Hospice Number of non-Medicaid patients who died while in the nursing home
during the census month whose level of care was Hospice. Include
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Field name Data
Medicaid applicants, pending patients, and all other non-Medicaid
patients. For example, those who have benefits through Medicare, VA,
and private insurance.
Transfers
SNF Number of non-Medicaid patients transferred from 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 transferred from 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.
ICF2 Number of non-Medicaid patients transferred from the nursing home
during the census month whose level of care was Intermediate Care
Facility—Level 2. Include Medicaid applicants, pending patients, and all
other non-Medicaid patients. For example, those who have benefits
through Medicare, VA, and private insurance.
ICF3 Number of non-Medicaid patients transferred from the nursing home
during the census month whose level of care was Intermediate Care
Facility—Level 3. 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 transferred from the nursing home
during the census month whose level of care was Intermediate Care
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 transferred from the nursing home
during the census month whose level of care was Non Classified. Include
Medicaid applicants, pending patients, and all other non-Medicaid
patients. For example, those who have benefits through Medicare, VA,
and private insurance.
Hospice Number of non-Medicaid patients transferred from 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.
Discharges
SNF Number of non-Medicaid patients discharged from 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
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Field name Data
patients. For example, those who have benefits through Medicare, VA,
and private insurance.
ICF1 Number of non-Medicaid patients discharged from 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.
ICF2 Number of non-Medicaid patients discharged from the nursing home
during the census month whose level of care was Intermediate Care
Facility—Level 2. Include Medicaid applicants, pending patients, and all
other non-Medicaid patients. For example, those who have benefits
through Medicare, VA, and private insurance.
ICF3 Number of non-Medicaid patients discharged from the nursing home
during the census month whose level of care was Intermediate Care
Facility—Level 3. 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 discharged from the nursing home
during the census month whose level of care was Intermediate Care
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 discharged from the nursing home
during the census month whose level of care was Non Classified. Include
Medicaid applicants, pending patients, and all other non-Medicaid
patients. For example, those who have benefits through Medicare, VA,
and private insurance.
Hospice Number of non-Medicaid patients discharged from 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.
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 submit a number of forms at the same time. (For more
information, see Sending transactions.)
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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.
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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).
REJECT REASON Description of error causing 270 Eligibility Request to be rejected for
provider information.
FOLLOW-UP Description of action required from provider if 270 Eligibility Request is
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.
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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).
REJECT REASON Description of error causing 270 Eligibility Request to be rejected for
beneficiary information.
FOLLOW-UP Description of action required from provider if 270 Eligibility Request is
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 COVERAGE 2 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 COVERAGE 3 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.
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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
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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 INFORMATION
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.
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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.
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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.
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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 INFORMATION
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
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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.
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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.
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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.
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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.
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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
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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.
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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.
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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.
BENEFICIARY ID Beneficiary‘s Arkansas Medicaid ID number.
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
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Field name Data
applies to that error, and a brief description of the error. For example,
HEADER
1071 PRIMARY CARE PHYSICIAN REQUIRED / NONE ASSIGNED
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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
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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.
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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.
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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.
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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.
BENEFICIARY ID Beneficiary‘s Arkansas Medicaid ID number.
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.
BENEFICIARY ID Beneficiary‘s Arkansas Medicaid ID number.
AID CATEGORY Aid category determining the benefits this beneficiary receives.
AID CATEGORY
DESCRIPTION
Description of aid category.
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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.
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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
Date sealant was applied to beneficiary's tooth 3.
SEALANT –
TOOTH 14
Date sealant was applied to beneficiary's tooth 14.
SEALANT –
TOOTH 15
Date sealant was applied to beneficiary's tooth 15.
SEALANT –
TOOTH 18
Date sealant was applied to beneficiary's tooth 18.
SEALANT –
TOOTH 19
Date sealant was applied to beneficiary's tooth 19.
SEALANT –
TOOTH 30
Date sealant was applied to beneficiary's 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.
BENEFICIARY ID Beneficiary‘s Arkansas Medicaid ID number.
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
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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
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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.
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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.
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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.
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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.
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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.
2. Select the file you want to view. The file displays in the open window.
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.
2. Select the file you want to view. The file displays in the open window.
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_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.
2. Select the file you want to view. The file displays in the open window.
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_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.
2. Select the file you want to view. The file displays in the open window.
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_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.
2. Select the file you want to view. The file displays in the open window.
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_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.
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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.
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Billing/Requesting Provider
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, 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.
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Field name Data
Provider Address
Address Provider‘s street address. DO NOT enter a P.O. box number here.
City Provider‘s city.
State 2-character postal abbreviation for state.
Zip First 5 digits of zip code are required. Space is available for +4 digits.
Last 4 digits are used when needed to identify a provider.
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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.
State 2-character postal abbreviation for state.
Zip First 5 digits of zip code are required. Space is available for +4 digits.
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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.
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Facility/Performing/Referring/Service Provider
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, 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.
City Provider‘s city.
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.
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Field name Data
Tax ID Type Values: EIN, SSN
SSN/EIN Provider‘s Social Security Number or Employer Identification Number.
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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.
City Provider‘s city.
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.
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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 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.
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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.
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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.
Description Definition of the code.
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Carrier
Field name Data
Carrier Code Code identifying the insurance carrier—the third party liability (TPL)
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.
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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.)
Description Definition of the code.
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Diagnosis
Field name Data
Diagnosis Code Code for the condition or disease being treated. (See International
Classification of Diseases coding manual).
Description Definition of the code.
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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.
Description Definition of the code.
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Occurrence
Field name Data
Occurrence Code Code defining a significant event relating to this claim. See the National
Uniform Billing committee (NUBC) manual.
Description Definition of the code.
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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.
Description Definition of the code.
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Place of Service
Field name Data
Place of Service
Code
Code for the location at which the service was delivered.
Description Definition of the code.
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Policy Holder
Field name Data
Beneficiary ID Beneficiary‘s 10-digit Arkansas Medicaid ID number.
Carrier Code Code identifying the insurance carrier—the third party liability (TPL)
carrier code assigned by the Arkansas Medicaid Program.
Select the code 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 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.
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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.
Zip First 5 digits of zip code are required. Space is available for +4 digits.
Patient Information
Insurance
Type Code
Select a code from the list.
Relationship
to Insured
Select a code from the list.
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Procedure/NDC
Field name Data
Procedure/NDC Identification code for the service provided or product dispensed.
Description Definition of the code.
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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.
Description Definition of the code.
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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.
Description Definition of the code.
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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.
Description Definition of the code.
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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.
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Field name Data
Beneficiary ID Beneficiary‘s 10-digit Arkansas Medicaid ID number.
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.
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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.
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Field name Data
Beneficiary ID Beneficiary‘s 10-digit Arkansas Medicaid ID number.
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.
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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.
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Tools
The Tools menu includes the following commands:
Archive
Database Recovery
Change Password
Options
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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.
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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.
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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:
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 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.
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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:
1. If PES is loaded on a network, ask all other users to exit PES.
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:
1. If PES is loaded on a network, ask all other users to exit PES.
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.)
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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.
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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.
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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)
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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.
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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.
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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.
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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
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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.
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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
Error Potential cause(s) Solution(s)
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).
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Error
code
Error Potential cause(s) Solution(s)
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.
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.
Error
code
Error Potential cause(s) Solution(s)
Could not
update the key
sak. The SQL
code was –1
Permissions for the arhipaa
folder are incorrect.
Ask your network administrator to
give you Read, Write, and Modify
permissions on the arhipaa folder
and all subfolders and files.
Arhipaa folder and/or its
subfolders and files are read
only.
Locate the folder where PES is
loaded (for example, C:\arhipaa).
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.
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Error
code
Error Potential cause(s) Solution(s)
Right-click the folder.
Click Properties.
If ―Read Only‖ is checked, uncheck
it.
Temp folder in the arhipaa folder
is missing or invalid.
Using Windows Explorer, locate
the folder C:\arhipaa\temp.
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.
Using Windows Explorer, locate
the folder C:\arhipaa\temp.
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
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.
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
loaded (for example, C:\arhipaa).
Right-click the arhipaa folder.
Click Properties.
If ―Read Only‖ is checked, uncheck
it.
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Error
code
Error Potential cause(s) Solution(s)
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.