Arkansas Medical Billing and Payer Rules

Timely Filing in Arkansas

Arkansas and the Federal No Surprises Act

CMS told Arkansas in December 2021 that federal IDR applies because the state has no All-Payer Model Agreement and identified no state law governing the out-of-network rate. We confirm plan type before filing any notice.

Major Payers

How Does Arkansas Medicaid Work for Billing?

Arkansas Medicaid is run by the Arkansas Department of Human Services (DHS) through its Division of Medical Services (DMS). DHS publishes billing rules in a provider manual: Section I covers general policy and participation, and Section III covers billing.

Two payment paths sit side by side. In fee-for-service, claims go to the state's fiscal agent, which DHS's provider FAQ names as Gainwell Technologies. In managed care, a plan pays under its own contract. Arkansas runs Medicaid managed care through two programs, ARHOME for most adults and PASSE for members with complex behavioral health or developmental disability needs, so the first check on any claim is which path the member was on at the date of service.

Paper is still accepted but is stricter than elsewhere. The DHS FAQ says the fiscal agent requires original red-ink (sensor coded) CMS-1500 forms rather than copies, because its scanners separate the red form fields from the blue or black claim data. The same FAQ allows up to 200 lines on a professional or dental claim and 999 on an institutional (UB-04) claim.

How Do You Fix a Claim That Paid Wrong?

The FAQ says an error is corrected with an edit, void or adjustment, and electronic adjustments in the portal are preferred. A paper adjustment must be sent with both the adjustment request and the updated claim to Gainwell Technologies, with "Corrected claim is attached" noted in the Description area. A refund check does not correct a claim that paid wrong because of other insurance: the FAQ says to void or adjust the claim and rebill with the right payment information, since a refund does not update the claim data.

What Are ARHOME and PASSE, and Who Pays Those Claims?

ARHOME, short for Arkansas Health and Opportunity for Me, replaced Arkansas Works on January 1, 2022, per the DHS ARHOME page. DHS says the program uses Medicaid dollars to buy private health insurance, and that coverage comes from one of two carriers, Blue Cross Blue Shield or Ambetter. Section I of the manual adds that ARHOME covers adults ages 19 to 64 earning up to 138 percent of the federal poverty level who are not eligible for Medicare.

The PASSE program, the Provider-Led Arkansas Shared Savings Entity, is separate. DHS describes it as a Medicaid initiative for people with complex behavioral health needs and intellectual or developmental disabilities. DHS's quality rating page links ratings for Arkansas Total Care, CareSource PASSE, Empower Healthcare Solutions and Summit Community Care among the PASSEs.

PASSE claims follow Section II of the PASSE manual. It says each PASSE must adjudicate 95 percent of clean claims within 30 days and 99 percent within 60 days of receipt. It also says a PASSE cannot deny a clean claim for timeliness when the claim reaches the responsible PASSE within the later of 60 days from a recoupment date, 12 months from the date of service, or 12 months from the date eligibility posts.

What Is the Timely Filing Limit for Arkansas Medicaid?

Arkansas Medicaid pays claims received within 12 months of the date of service. Section 302.000 of the Section III billing manual quotes 42 CFR 447.45(d)(1), which requires the agency to require claims no later than 12 months from the date of service, and the DHS FAQ repeats the 12-month answer for claims denied for timely filing.

The manual says the 12-month rule covers three kinds of claim: services for people with both Medicare and Medicaid, adjustments and resubmissions of claims already considered, and services for people who gain Medicaid eligibility retroactively. It also says there are no exceptions to the policy, then lists flexibility that applies to those who follow the definitions closely.

Providers may not electronically transmit claims for dates of service more than 12 months old to the fiscal agent. A claim filed after 12 months is not a clean claim, except in the special circumstances the manual sets out.

What If the Member Was Not yet Eligible?

Section 302.000 tells providers to bill with the pseudo beneficiary ID 9999999999 when eligibility is still pending. Medicaid will deny the claim, and the denial is your proof of timely filing if eligibility is approved more than 12 months after the date of service. The provider then has 12 months from the approval date to resubmit a clean claim, and after that the claim denies for timely filing. The manual makes the provider responsible for checking the approval date.

How Do Medicare and Medicaid Crossover Claims Work in Arkansas?

Bill Medicare first, then bill the balance to Medicaid as a crossover claim. The DHS FAQ says that when Medicare pays part of a claim or applies the charge to the deductible, you submit a crossover institutional or crossover professional claim through the portal's Claims tab. A paper crossover goes with a CMS-1500 or CMS-1450 and form DMS-600, the Medicare EOMB information sheet, to Gainwell Technologies at PO Box 34440, Little Rock, AR 72203.

Section 302.000 gives a timing safeguard. A Medicare claim filed within the 12-month Medicaid window establishes Medicaid timely filing, even if Medicare crosses the claim after a year. For Medicare denials, the FAQ says to bill Medicaid as primary on an original red-ink claim with the denial attached, to the research analyst at PO Box 8036, Little Rock, AR 72203. Services Medicare does not cover can go to Medicaid as primary without a denial.

How Do You Appeal a Denied Claim with Arkansas DHS?

Under Section 161.200 of the Section I manual, a provider may ask for administrative reconsideration in writing within 30 calendar days of notice of an adverse decision. The request must include the notice and any documentation supporting medical necessity. The manual says reconsideration does not postpone the adverse action.

If you want to appeal, Section 161.300 allows an appeal of any non-sanction adverse action within 30 calendar days of the notice, or 10 calendar days after a reconsideration decision that upholds the action, whichever is later. The manual says each period starts five days after the date of the written notice, and the appeal goes to the Office of Medicaid Provider Appeals. It must say in detail which findings you say are unsupported.

Managed care differs. For a PASSE denial, Section II says the provider may appeal on its own behalf when the action denies a claim for covered care already given, and the PASSE must follow the Arkansas Administrative Procedure Act. A PASSE must send notice of an adverse action on previously authorized care at least 10 days before acting, following 42 CFR 431.211. See our denial management service for how we track these clocks.

Do You Enroll Separately for Each Location and Provider, and How Often Is Revalidation?

Medicaid assigns a provider number linked to the tax identification number and the NPI, per Section 141 of the Section I manual. Applications for a new practice location are screened like initial applications under 42 CFR 455.450, so a new site is not a paperwork shortcut.

Revalidation is on a clock. Section 141.100 says 42 CFR 455.414 requires Arkansas Medicaid to revalidate every provider at least every 5 years, with a new application, any application fee and screening. The notice is mailed 90 days before the deadline to the Mail To address on file. Missing the deadline interrupts claim payment, so we track every revalidation date and keep that address current.

Who Is the Medicare MAC for Arkansas?

Novitas Solutions, Inc. is the A/B Medicare Administrative Contractor for Arkansas, in Jurisdiction H. CMS's MAC-by-state document lists Jurisdiction H as Arkansas, Colorado, New Mexico, Oklahoma, Texas, Louisiana and Mississippi, all under Novitas. CGS Administrators, LLC is the DME MAC for Arkansas in DME Jurisdiction C.

Under 42 CFR 424.44(a)(1), a Medicare claim must be filed no later than the close of the period ending 1 calendar year after the date of service. That is the same one-year idea as Arkansas Medicaid, so a dual-eligible claim has to clear both clocks.

What Is the Prompt Pay Rule for Arkansas Insurers?

A health carrier must pay or deny a clean claim within 30 days of receipt if submitted electronically, or 45 days if submitted by other means. This is 23 CAR 15-110(b), part of the Insurance Department's Unfair Claims Settlement Practices rule (formerly Rule 43). The carrier must also tell the claimant within 30 days if the claim needs more information under 23 CAR 15-111.

A carrier that misses the deadline owes a penalty starting on the 61st day after receipt of the clean claim. The penalty is the payment amount times 12 percent per year times the days late, divided by 365, and it is paid without any action by the claimant under 15-110(d).

The rule defines a clean claim as one on a HCFA 1500, a UB92, a HIPAA format or the carrier's standard form, with required fields filled in per its published filing requirements. It excludes claims needing more information under 15-111(c), such as coordination of benefits checks.

Scope matters. 23 CAR 15-103(b)(8) defines a health carrier as an HMO, hospital medical service corporation or disability insurer, and extends the term to self-insured governmental and church plans and their third-party administrators. It excludes self-insured employer health benefit plans.

Does Arkansas Have Its Own Surprise Billing Law?

CMS's December 21, 2021 letter to Arkansas says the state has no All-Payer Model Agreement and did not identify any state law governing the out-of-network rate. So federal IDR applies to out-of-network items and services for people in insured group plans and for group or individual coverage in Arkansas, and the Arkansas Insurance Department enforces the outcome. That letter is the latest CMS statement cited here, and state law can change. Plan type decides the pathway, so see our guide to state surprise billing laws and our out-of-network billing and IDR service.

The letter splits enforcement. The Insurance Department said it would enforce sections 2719, 2799A-2(a), 2799A-3, 2799A-4 and 2799A-5 of the PHS Act against issuers. It said it lacks authority over provider and facility provisions such as 2799B-1, 2799B-2 and 2799B-3, so CMS enforces those directly against providers and facilities in Arkansas.

The CMS Q&A says the No Surprises Act supplements state laws and that a state cannot enforce its protections against a self-insured group plan unless the plan opted in. Balance billing a patient for emergency care is covered by the federal rules for most plans, not by an Arkansas out-of-network statute we could open. This page cites no Arkansas ground ambulance rate law, so it does not say whether one exists.

How Do You File a Complaint with the Arkansas Insurance Department?

The Arkansas Insurance Department takes complaints about insurance companies and agents through an online form, by email, by fax to (501) 371-2749 or by mail to its Consumer Services Division, 1 Commerce Way, Suite 102, Little Rock, AR 72202-2087. Its complaint page lists a separate Health Care Provider Complaint Form.

How Long Can an Arkansas Insurer Claw Back a Payment?

A health insurer may exercise recoupment only during the 18 months after it paid the claim, except for fraud it could not have found sooner. That is 23 CAR 123-102(a), which also says the insurer cannot extend the period just because it is still investigating. The insurer must give a written statement of the basis and notice of any internal appeal right.

What Is Different About Hospital UB-04 Billing to Arkansas Medicaid?

Section II of the Hospital manual has a heading for Inpatient and Outpatient Hospital CMS-1450 (UB-04) billing procedures, which refers billers to the official UB-04 data specifications. The manual says the type of bill is a four-digit code with a leading zero, and on a first or continuing inpatient claim the patient status code in field 17 must show the patient is still in house through the end date.

Medicaid pays hospitals interim per diem rates. Per Section 250.201, each year DMS recalculates the rate from the hospital's un-audited cost report by dividing Medicaid allowable costs by Medicaid covered days paid, and applies it from the first day of the new fiscal year. Long stays crossing a fiscal year need a second interim claim whose from date is that first day. Cost settlement follows, so see our hospital and facility billing page for how we reconcile it.

Which Payers Matter Most in Arkansas?

The payers we can show from official sources are the state's own programs and contractors. They are Arkansas Medicaid fee-for-service, the two ARHOME carriers (Blue Cross Blue Shield and Ambetter, as DHS names them), the PASSEs, and Novitas Solutions for Medicare Part A and B. No state market share report backs a commercial ranking, so we name none.

How We Handle Billing in Arkansas

We sort each Arkansas claim by payer path first: fee-for-service with the 12-month clock, an ARHOME carrier or PASSE with its own manual, Medicare with Novitas at one calendar year, or a commercial plan and its contract. Claims go out within 24 hours of charge entry and denials are worked within 48 hours.

For out-of-network disputes we check whether the plan is fully insured or self-funded before choosing a pathway, and we calendar the Insurance Department's 30 and 45 day marks and the 18 month recoupment limit. Book a call and we will review your Arkansas payer mix with you.