ࡱ>  Bbjbj\\ Fl>i1g>i1g:F((''''''''8()'vn0\8r8r8r89K$Q9v;v;v;v;v;v;v$By{f_v'b99bb_v''r8r84tv$4l4l4lbf'r8'r89v4lb9v4l4l6q9sr80ǗB$dr%vv<vr@^|f^|89s9s^|'MsS$ W>4lJY[SSS_v_viSSSvbbbb^|SSSSSSSSS(X &: section ii - RURAL HEALTH CLINIC contents TOC \o "1-9" \n \h \z \t "chead1,1,chead2,2"  HYPERLINK \l "_Toc71204834" 200.000 RURAL HEALTH CLINIC GENERAL INFORMATION  HYPERLINK \l "_Toc71204835" 201.000 Arkansas Medicaid Participation Requirements for Rural Health Clinic (RHC) Providers  HYPERLINK \l "_Toc71204836" 201.001 Electronic Signatures  HYPERLINK \l "_Toc71204837" 201.100 Providers in Arkansas and Bordering States  HYPERLINK \l "_Toc71204838" 201.110 Routine Services Providers  HYPERLINK \l "_Toc71204839" 201.200 Providers in Non-Bordering States  HYPERLINK \l "_Toc71204840" 201.210 Limited Services Providers  HYPERLINK \l "_Toc71204841" 202.000 Medical Records  HYPERLINK \l "_Toc71204842" 203.000 The Role of the RHC in the Child Health Services (EPSDT) Program  HYPERLINK \l "_Toc71204843" 204.000 RHCs Role in the Early Intervention Part C Program  HYPERLINK \l "_Toc71204844" 210.000 PROGRAM COVERAGE  HYPERLINK \l "_Toc71204845" 211.000 Scope  HYPERLINK \l "_Toc71204846" 211.100 Rural Health Clinic Core Services  HYPERLINK \l "_Toc71204847" 211.200 Definition of Incident To Services  HYPERLINK \l "_Toc71204848" 211.210 Services and Supplies Incident To a Physicians Professional Service  HYPERLINK \l "_Toc71204849" 211.220 Services and Supplies Incident To a Nurse Practitioners or Physician Assistants Service  HYPERLINK \l "_Toc71204850" 211.300 Interactive Electronic (Telemedicine) Encounters  HYPERLINK \l "_Toc71204851" 212.000 Rural Health Clinic Ambulatory Services  HYPERLINK \l "_Toc71204852" 212.100 Rural Health Clinic Provider Based Ambulatory Services  HYPERLINK \l "_Toc71204853" 212.200 Independent (Free-Standing) Rural Health Clinic Ambulatory Services  HYPERLINK \l "_Toc71204854" 212.210 Rural Health Clinic (RHC) Non-Core Services  HYPERLINK \l "_Toc71204855" 213.000 Staff Requirements and Responsibilities  HYPERLINK \l "_Toc71204856" 214.000 A Patient of the RHC  HYPERLINK \l "_Toc71204857" 215.000 Off-Site RHC Services  HYPERLINK \l "_Toc71204858" 216.000 Limitations and/or Non-Covered Services  HYPERLINK \l "_Toc71204859" 217.000 Family Planning  HYPERLINK \l "_Toc71204860" 217.100 Family Planning Visits  HYPERLINK \l "_Toc71204861" 217.110 Basic Family Planning Visits  HYPERLINK \l "_Toc71204862" 217.120 Periodic Family Planning Visits  HYPERLINK \l "_Toc71204863" 217.130 Post-Sterilization Visits  HYPERLINK \l "_Toc71204864" 217.200 Contraception  HYPERLINK \l "_Toc71204865" 217.210 Prescription and Non-Prescription Contraceptives  HYPERLINK \l "_Toc71204866" 217.220 Other Contraceptive Methods  HYPERLINK \l "_Toc71204867" 217.230 Sterilization  HYPERLINK \l "_Toc71204868" 217.231 Informed Consent to Sterilization  HYPERLINK \l "_Toc71204869" 218.000 Benefit Limits  HYPERLINK \l "_Toc71204870" 218.100 RHC Encounter Benefit Limits  HYPERLINK \l "_Toc71204871" 218.200 Family Planning Benefit Limits  HYPERLINK \l "_Toc71204872" 218.210 Basic Family Planning Visit  HYPERLINK \l "_Toc71204873" 218.220 Periodic Family Planning Visit  HYPERLINK \l "_Toc71204874" 218.230 Reserved  HYPERLINK \l "_Toc71204875" 218.240 Contraception  HYPERLINK \l "_Toc71204876" 218.241 Prescription and Non-Prescription Contraceptives  HYPERLINK \l "_Toc71204877" 218.300 Extension of Benefits  HYPERLINK \l "_Toc71204878" 218.310 Benefit Extension Requests  HYPERLINK \l "_Toc71204879" 218.311 Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services, form DMS-671  HYPERLINK \l "_Toc71204880" 218.312 Documentation Requirements  HYPERLINK \l "_Toc71204881" 218.313 Provider Notification of Benefit Extension Determinations  HYPERLINK \l "_Toc71204882" 218.314 Reconsideration of Benefit Extension Denials  HYPERLINK \l "_Toc71204883" 218.320 Appealing an Adverse Action  HYPERLINK \l "_Toc71204884" 218.400 Benefit Limits for Other Ambulatory Services Encounters  HYPERLINK \l "_Toc71204885" 230.000 PRIOR AUTHORIZATION  HYPERLINK \l "_Toc71204886" 240.000 REIMBURSEMENT  HYPERLINK \l "_Toc71204887" 240.100 Reimbursement Methodologies for Dates of Service Before January 1, 2001  HYPERLINK \l "_Toc71204888" 240.110 Methods of ReimbursementProvider Based RHCs, for Dates of Service Before January 1, 2001  HYPERLINK \l "_Toc71204889" 240.120 Methods of ReimbursementIndependent RHCs, for Dates of Service Before January 1, 2001  HYPERLINK \l "_Toc71204890" 241.000 Reimbursement Methodology for Dates of Service On and After January 1, 2001  HYPERLINK \l "_Toc71204891" 242.000 Submitting Cost Reports  HYPERLINK \l "_Toc71204892" 242.010 Fee Schedule  HYPERLINK \l "_Toc71204893" 243.000 Rate Appeal and/or Cost Settlement Appeal Process  HYPERLINK \l "_Toc71204894" 250.000 BILLING PROCEDURES  HYPERLINK \l "_Toc71204895" 251.000 Introduction to Billing  HYPERLINK \l "_Toc71204896" 252.000 CMS-1450 (UB-04) Billing Procedures  HYPERLINK \l "_Toc71204897" 252.100 Revenue Codes  HYPERLINK \l "_Toc71204898" 252.101 Billing Instructions for Family Planning Visits  HYPERLINK \l "_Toc71204899" 252.102 Billing Instructions for EPSDT and ARKids First-B Medical Screenings  HYPERLINK \l "_Toc71204900" 252.103 Billing of Multi-Use and Single-Use Vials  HYPERLINK \l "_Toc71204901" 252.110 Non-Payable Diagnosis Codes  HYPERLINK \l "_Toc71204902" 252.120 Diagnosis Codes not Covered for Beneficiaries under 21  HYPERLINK \l "_Toc71204903" 252.200 Place of Service and Type of Service Codes  HYPERLINK \l "_Toc71204904" 252.300 Billing InstructionsPaper Claims  HYPERLINK \l "_Toc71204905" 252.310 Completion of CMS-1450 (UB-04) Claim Form  HYPERLINK \l "_Toc71204906" 252.400 Special Billing Procedures  HYPERLINK \l "_Toc71204907" 252.401 Upper Respiratory Infection Acute Pharyngitis  HYPERLINK \l "_Toc71204908" 252.402 Medication Assisted Treatment  200.000 RURAL HEALTH CLINIC GENERAL INFORMATION201.000 Arkansas Medicaid Participation Requirements for Rural Health Clinic (RHC) Providers10-15-09Rural Health Clinic services providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program: Providers must be certified by the Centers for Medicare and Medicaid Services as a Rural Health Clinic and participate in the Title XVIII (Medicare) Program. A copy of the current Medicare Certification must accompany the provider application packet and Medicaid contract. 201.001 Electronic Signatures10-8-10Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code 25-31-103 et seq. 201.100 Providers in Arkansas and Bordering States10-13-03Providers in Arkansas and the six bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas) may be enrolled as routine services providers if they meet all Arkansas Medicaid participation requirements outlined above. 201.110 Routine Services Providers1-1-04A. Routine services providers may be enrolled in the program as providers of routine services. B. Claims must be filed according to the specifications in this manual. 201.200 Providers in Non-Bordering States3-1-11Providers in non-bordering states may enroll only as limited services providers. 201.210 Limited Services Providers3-1-11A. Limited services providers may enroll in the Arkansas Medicaid program to provide prior authorized or emergency services only. Emergency services are defined as inpatient or outpatient hospital services that a prudent layperson with an average knowledge of health and medicine would reasonably believe are necessary to prevent death or serious impairment of health and which, because of the danger to life or health, require use of the most accessible hospital available equipped to furnish those services. Source: 42 U.S. Code of Federal Regulations 422.2 and 424.101. Prior authorized services are those that are medically necessary and not available in Arkansas. Each request for these services must be made in writing, forwarded to the Utilization Review Section and approved before the service is provided. See Section 230.000 of this manual for instructions for obtaining prior authorization. To enroll, a non-bordering state provider must download an Arkansas Medicaid application and contract from the Arkansas Medicaid website and submit the application, contract and claim to Arkansas Medicaid Provider Enrollment. A provider number will be assigned upon approval of the provider application and Medicaid contract. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMSUR.doc"View or print the Utilization Review Section contact information. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/ApplicationPacket.doc"View or print the provider enrollment and contract package (Application Packet). HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/ProviderEnrol.doc"View or print Medicaid Provider Enrollment Unit contact information. B. Limited services provider claims will be manually reviewed prior to processing to ensure that only emergency or prior authorized services are approved for payment. These claims should be mailed to the Division of Medical Services, Program Communications Unit. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMSProgramCom.doc"View or print the Arkansas Division of Medical Services, Program Communications Unit contact information. 202.000 Medical Records10-15-09Documentation, record keeping and Medicaid participation requirements are detailed within Section 140.000, Provider Participation, of this manual. Additionally, RHCs are required to keep the following records: 1. Specific services provided 2. The date and the actual time of the services 3. Who provided each service 4. Chief complaint on each visit 5. Tests and results 6. Diagnosis 7. Treatment, including prescriptions 8. Signature or initials of physician or attending health professional after each visit 203.000 The Role of the RHC in the Child Health Services (EPSDT) Program10-13-03The Arkansas Medical Assistance Program includes a Child Health Services (Early and Periodic Screening, Diagnosis and Treatment) Program for eligible individuals under 21 years of age. The purpose of this program is to detect and treat health problems in their early stages. RHCs may enroll in the Child Health Services Program to perform EPSDT screenings by referral from eligible childrens PCPs. 204.000 RHCs Role in the Early Intervention Part C Program10-13-03Health care providers offering any early intervention service to an eligible child must refer the child to the Division of Developmental Disabilities Services for possible enrollment in First Connections, the Early Intervention Part C Program in Arkansas. Federal regulations at 34 CFR 303.321.d.2.ii require health care professionals and day care centers to refer potentially eligible children within two days of identifying them as candidates for early intervention. A child must be referred if he or she is aged birth to three and meets one or more of the following criteria: A. Developmental Delaya delay of 25% or greater in one of the following areas of development: 1. Physical (gross/fine motor), 2. Cognitive, 3. Communication, 4. Social/emotional or 5. Adaptive and self-help skills. B. Diagnosed physical or mental conditionexamples of such conditions include but are not limited to: 1. Downs Syndrome and chromosomal abnormalities associated with mental retardation, 2. Congenital syndromes associated with delays such as Fetal Alcohol Syndrome, intra-uterine drug exposure, prenatal rubella, severe microcephaly and macrocephaly, 3. Maternal Acquired Immune Deficiency Syndrome (AIDS) and 4. Sensory impairments such as visual or hearing disorders. The Division of Developmental Disabilities is the lead agency for Part C Early Intervention in Arkansas. Referrals must be made on form DDS/FS#0001.a, Referral/Application For Services. The referring provider must retain a copy of the completed referral form with the childs medical records. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DDS-FS-0001-a.doc"View or print DDS/FS#0001.a. Contact the local DHS office in the childs county of residence for the name of the DDS service coordinator and/or the DDS licensed community program to which the child should be referred. 210.000 PROGRAM COVERAGE211.000 Scope6-1-09The Medical Assistance (Medicaid) Program is designed to assist eligible Medicaid beneficiaries in obtaining medical care within the guidelines specified in this manual. All Medicaid benefits are based on medical necessity. See the Glossary for the definition of medical necessity. A. A provider-based rural health clinic is one which is an integral part of a hospital, skilled nursing facility or home health agency that participates in Medicare and which is licensed, governed and supervised with other departments of the facility. B. An independent (free-standing) rural health clinic is one that participates in Medicare and is not provider based. C. Visit is defined as a face-to-face encounter between a clinic patient and a physician, physician assistant, nurse practitioner, nurse midwife or other specialized nurse practitioner whose services are reimbursed under the rural health clinic payment method. Encounters with more than one health care professional and multiple encounters with the same health care professional that take place on the same day and at a single location constitute a single visit, except when the patient, after the first encounter, suffers illness or injury requiring additional diagnosis or treatment. 211.100 Rural Health Clinic Core Services9-1-20Rural Health Clinic core services are as follows: A. Professional services that are performed by a physician at the clinic or are performed away from the clinic by a physician whose agreement with the clinic provides that he or she will be paid by the clinic for such services; B. Services and supplies furnished incident to a physicians professional services; C. Services provided by non-physician, services of physician assistants, nurse practitioners, nurse midwives, and specialized nurse practitioners when the provider is legally: 1. employed by, or receiving compensation from a rural health clinic; 2. under the medical supervision of a physician; 3. acting in accordance with any medical orders for the care and treatment of a patient prepared by a physician; and 4. acting within their scope of practice by providing services they are legally permitted to perform by the state in which the service is provided if the services would be covered if furnished by a physician; D. Services and supplies that are furnished as an incident to professional services furnished by a nurse practitioner, physician assistant, nurse midwife, or other specialized nurse practitioner; E. Visiting nurse services on a part-time or intermittent basis to home-bound patients in areas in which there is a shortage of home health agencies. Note: For purposes of visiting nurse care, a home-bound patient is one who is permanently or temporarily confined to his or her place of residence because of a medical or health condition. Institutions, such as a hospital or nursing care facility, are not considered a patients residence. Note: A patients place of residence is where he or she lives, unless he or she is in an institution such as a nursing facility, hospital, or intermediate care facility for individuals with intellectual disabilities (ICF/IID); and F. Effective for dates of service on and after September 1, 2020, Medication Assisted Treatment (MAT) for Opioid Use Disorders is available to all qualifying Medicaid beneficiaries when provided by providers who possess an X-DEA license on file with Arkansas Medicaid Provider Enrollment for billing purposes. All rules and regulations promulgated within the Physicians provider manual for provision of this service must be followed. 211.200 Definition of Incident To Services211.210 Services and Supplies Incident To a Physicians Professional Service10-13-03Services and supplies incident to a physicians professional service are covered if the service or supply is: A. Of a type commonly furnished in physicians offices; B. Of a type commonly furnished without charge or included in the RHCs bill; C. Furnished as an incidental, although integral, part of a physicians professional services; D. Furnished under the direct, personal supervision of a physician and E. In the case of a service, furnished by a member of the clinics health care staff who is an employee of the clinic. Only drugs and biologicals that cannot be self-administered are included within the scope of this benefit. 211.220 Services and Supplies Incident To a Nurse Practitioners or Physician Assistants Service10-13-03Services and supplies incident to a nurse practitioners or physician assistants services are covered if the service or supply is: A. Of a type commonly furnished in physicians offices; B. Of a type commonly furnished without charge or included in the RHCs bill; C. Furnished as an incidental, although integral, part of the professional services of a nurse practitioner or physician assistant; D. Furnished under the direct, personal supervision of a nurse practitioner, physician assistant, nurse midwife, specialized nurse practitioner or a physician and E. In the case of a service, furnished by a member of the clinics health care staff who is an employee of the clinic. The direct personal supervision requirement is met in the case of a nurse practitioner, physician assistant, nurse midwife or specialized nurse practitioner only if such a person is permitted to supervise such services under the written policies governing the RHC. Only drugs and biologicals that cannot be self-administered are included within the scope of this benefit. 211.300 Interactive Electronic (Telemedicine) Encounters10-13-03Arkansas Medicaid covers RHC encounters and two ancillary services (fetal echography and echocardiography) as "telemedicine" services. Arkansas Medicaid defines telemedicine services as medical services performed as electronic transactions in real time. In order for a telemedicine encounter to be covered by Medicaid, the practitioner and the patient must be able to see and hear each other in real time. Physician interpretation of fetal ultrasound is covered as a telemedicine service if the physician views the echography or echocardiography output in real time while the patient is undergoing the procedure. 212.000 Rural Health Clinic Ambulatory Services10-13-03RHCs providing other ambulatory services must enroll in the applicable Medicaid program in order for the services to be covered. 212.100 Rural Health Clinic Provider Based Ambulatory Services10-13-03Provider based RHC ambulatory services are defined as any other ambulatory service included in the Medicaid State Plan if the RHC provider offers such a service, (e.g., Dental, Visual, etc.). Refer to Section 240.100 for information concerning Provider Based RHCs methods of reimbursement for ambulatory services. 212.200 Independent (Free-Standing) Rural Health Clinic Ambulatory Services10-13-03Independent (free-standing) RHC ambulatory services are defined as any other ambulatory service included in the Medicaid State Plan if the RHC provider offers such a service, (e.g., Dental, Visual, etc.). 212.210 Rural Health Clinic (RHC) Non-Core Services10-13-03A. The following services are not to be Rural Health Clinic (RHC) core services. 1. Emergency and non-emergency outpatient hospital visits, 2. Inpatient hospital visits, 3. Surgeries performed in the inpatient or outpatient hospital or in an ambulatory surgical center, 4. Technical components of radiology procedures and 5. Technical components of electrocardiograms and echocardiography. B. Inpatient and outpatient hospital visits, home and nursing facility visits and other off-site visits remain core services if the physician or nurse practitioner must, as a condition of his or her employment by or contract with the RHC, see patients at sites away from the RHC and is compensated by the RHC. C. Physicians and nurse practitioners enrolled in the Arkansas Medicaid Program may bill for RHC non-core services according to the guidelines in their respective Medicaid manuals. D. Rural Health Clinics desiring to bill for RHC non-core physician services must enroll with Arkansas Medicaid as physician group providers, even if they intend to bill for the services of only one physician. See Section II of the Arkansas Medicaid Physician/Independent Lab/CRNA/Radiation Therapy Center manual for participation requirements. E. Rural Health Clinics desiring to bill for RHC non-core nurse practitioner services must enroll with Arkansas Medicaid as nurse practitioner group providers, even if they intend to bill for the services of only one nurse practitioner. See Section II of the Arkansas Medicaid Nurse Practitioner manual for participation requirements. 213.000 Staff Requirements and Responsibilities1-1-18A. The RHC must have a health care staff that includes one or more physicians and one or more physician assistants or nurse practitioners. The physicians, physician assistants or nurse practitioners may be the owners of the RHC and/or under agreement with the RHC to carry out the responsibilities required. B. The staff may include ancillary personnel who are supervised by the professional staff. C. A physician, physician assistant or nurse practitioner must be available to furnish patient care services at times the RHC operates. These staff must be available to furnish patient care services at least 50% of the time the RHC operates. D. The physician must provide medical direction for the RHC activities and consultation for the medical supervision of the health care staff. The physician also must participate in developing, executing and periodically reviewing policies, services, patient records and must provide medical orders and medical care services to patients of the RHC. E. The physician assistant and nurse practitioner, as members of the RHC staff, must participate in the development, execution and periodic review of the written policies governing the services the RHC furnishes and participate with the physician in a periodic review of patients health records. F. The physician assistant or nurse practitioner must perform the following functions, to the extent they are not being performed by a physician: 1. Provide services in accordance with RHC policies; 2. Arrange for or refer patient for services that cannot be provided by the RHC; and 3. Assure adequate patient health records are maintained and transferred as required when patients are referred. 4. Some services such as personal care require an Independent Assessment. Please refer to the Independent Assessment Guide for related information. 214.000 A Patient of the RHC6-1-09Any Medicaid beneficiary who receives RHC services and/or other ambulatory services at the RHC is considered a patient of the RHC. Also, any Medicaid beneficiary who receives RHC services by the RHC off-site from the RHC is considered a patient of the RHC. 215.000 Off-Site RHC Services10-13-03RHC services are covered under the RHC benefit when furnished off-site only when the employed practitioner of the RHC furnishes the services on behalf of the RHC, or the RHC practitioners agreement with the RHC requires he or she provide the services and seek compensation from the RHC. 216.000 Limitations and/or Non-Covered Services10-13-03RHC services are subject to the limitation and coverage restrictions that exist for medical services provided in other settings. Services not covered by the Arkansas Medicaid Program include, but are not limited to, the following: A. The services of nurse practitioners, physician assistants, nurse midwives or specialized nurse practitioners if state law or regulations require that the services be performed under a physicians order and no such order was prepared. B. Services that are not considered medically necessary. C. Services that are not properly documented. D. Visits in which a direct relationship does not exist between the patient and a physician, a physician assistant or nurse practitioner (e.g., visit to pick up a prescription, telephone consultation, etc.) E. Cosmetic surgery performed primarily for aesthetic purposes only (e.g., ear piercing, tattoo removal, etc.) F. Well child care, routine physical examinations or examinations for school. (See the Child Health Services (EPSDT) Manual, Section II, for coverage of these services and for billing instructions.) G. Dietary counseling. H. Most screening-type services unless being used to make a diagnosis (e.g., hypertension H screening, diabetes screening, hair analysis, etc.) I. Literature, booklets and other educational services. 217.000 Family Planning217.100 Family Planning Visits10-13-03An RHC encounter is covered as a family planning visit if: A. The visit meets the criteria of either the Basic Family Planning Visit or the Periodic Family Planning Visit, as described in A and B below, and B. A documented diagnosis of family planning is the primary reason or justification for the visit. 217.110 Basic Family Planning Visits6-1-09The Basic Family Planning Visit includes: A. Medical history and medical examination that includes: head, neck, breast, chest, pelvis, abdomen, extremities, weight and blood pressure. B. Counseling and education regarding 1. Breast self-exam, 2. The full range of contraceptive methods available and 3. HIV/STD prevention. C. Prescription for any contraceptives selected by the beneficiary. D. Laboratory services, including: 1. Pregnancy test, 2. Urinalysis testing for albumin and glucose, 3. Hemoglobin and Hematocrit, 4. Papanicolaou smear for cervical cancer, 5. Sickle cell screening and 6. Testing for sexually transmitted diseases 217.120 Periodic Family Planning Visits10-13-03Medicaid neither requires periodic visits nor specifies intervals between them. The visits may occur as needed. A. The Periodic Family Planning Visit includes: 1. Follow-up medical history, weight and blood pressure and 2. Counseling regarding contraceptives and possible complications of contraceptives B. The purpose of the periodic visit is to: 1. Evaluate the patients contraceptive program; 2. Renew or change the contraceptive prescription and 3. Provide the patient with additional opportunities for counseling regarding reproductive health and family planning. 217.130 Post-Sterilization Visits12-18-15Individuals who are eligible in a Title XIX State Plan (Regular Medicaid) Aid Category and for whom such a service is medically necessary, may obtain the needed care as a regular Medicaid benefit, subject to any applicable coverage or benefit limitations. 217.200 Contraception217.210 Prescription and Non-Prescription Contraceptives10-13-03A. Medicaid covers birth control pills and other prescription contraceptives under the family planning prescription benefit. B. Medicaid covers non-prescription contraceptives under the family planning benefit, when a physician writes a prescription for them. 217.220 Other Contraceptive Methods10-13-03Additional contraceptive methods covered by Medicaid are: A. The Norplant System, its implantation and removal, B. Intrauterine devices (IUD) and C. Depo-Provera injections 217.230 Sterilization12-18-15Sterilization is a covered benefit in the RHC program only when sterilization takes place in the RHC. A. Medicaid covers sterilization of men and women. 1. All adult (aged 21 or older) male and female Medicaid beneficiaries who are mentally competent are eligible for sterilization procedures and medically necessary follow-ups as long as they remain Medicaid-eligible. B. Medicaid coverage of sterilizations is contingent upon the provider's documented compliance with federal and state regulations, including obtaining the patient's signed consent in a manner prescribed by law. C. Non-therapeutic sterilization means any procedure or operation for which the primary purpose is to render an individual permanently incapable of reproducing. 1. Non-therapeutic sterilization is neither: a. A necessary part of the treatment of an existing illness or injury nor b. Medically indicated as an accompaniment of an operation of the genitourinary tract. 2. The reason the individual decides to take permanent and irreversible action is irrelevant. It may be for social, economic or psychological reasons or because a pregnancy would be inadvisable for medical reasons. D. Prior authorization is not required for a sterilization procedure. However, all applicable criteria described in this manual must be met. E. Federal regulations are very explicit concerning coverage of non-therapeutic sterilization. Therefore, all the following conditions must be met: 1. The person on whom the sterilization procedure is to be performed voluntarily requests such services. 2. The person is mentally and legally competent to give informed consent. 3. The person is 21 years of age or older at the time informed consent is obtained. 4. The person to be sterilized shall not be an institutionalized individual. The regulations define "institutionalized individual" as a person who is: a. Involuntarily confined or detained under a civil or criminal statute in a correctional or rehabilitative facility, including those for mental illness, or b. Confined under a voluntary commitment in a mental hospital or other facility for the care and treatment of mental illness. 5. The person has been counseled, both orally and in writing, concerning the effect and impact of sterilization and alternative methods of birth control. 6. Informed consent and counseling must be properly documented. Only the official Sterilization Consent Form DMS-615, properly completed, complies with documentation requirements. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-615Checklist.doc"View or print Sterilization Consent Form DMS-615. 7. Copies may be ordered from the Arkansas Medicaid fiscal agent. See Section III. If the patient needs the Sterilization Consent Form in an alternative format, such as large print, contact our Americans with Disabilities Act Coordinator. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/ADACoordinator.doc"View or print Americans with Disabilities Act Coordinator contact information. 8. Available by order from the Arkansas Medicaid fiscal agent are two free informational publications: Sterilization Consent Form-Information for Women (PUB-019) and Sterilization Consent Form-Information for Men (PUB-020). See Section III of any Arkansas Medicaid provider manual for instructions for ordering forms and publications. 9. If you have any questions regarding any of these requirements, contact the Arkansas Medicaid Program before the sterilization. 217.231 Informed Consent to Sterilization7-15-12A. By signing the Sterilization Consent Form DMS-615, the patient certifies that she or he understands the entire process. 1. By signing the consent form, the person obtaining consent and the physician certify that, to the best of their knowledge, the patient is mentally competent to give informed consent. 2. If any questions concerning this requirement arise, you should contact the Arkansas Medicaid Program for clarification before the sterilization procedure is performed. B. The person obtaining the consent for sterilization must sign and date the form after the beneficiary and interpreter sign, if an interpreter is used. 1. This may be done immediately after the beneficiary and interpreter sign, or it may be done later, but it must always be done before the sterilization procedure. 2. The signature will attest to the fact that all elements of informed consent were given and understood and that consent was voluntarily given. C. By signing the physician's statement on the consent form, the physician is certifying that shortly before the sterilization was performed, he or she again counseled the patient regarding the sterilization procedure. 1. The State defines "shortly before" as one week (seven days) or less before the performance of the sterilization procedure. 2. The physician's signature on the consent form must be an original signature and not a rubber stamp. D. Informed consent may not be obtained while the person to be sterilized is: 1. In labor or childbirth, 2. Seeking to obtain or obtaining an abortion, or 3. Under the influence of alcohol or other substances that affect the individual's state of awareness. E. The sterilization must be performed at least 30 days, but not more than 180 days, after the date of informed consent. The following exceptions to the 30-day waiting period must be properly documented on the form DMS-615. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-615Checklist.doc"View or print Sterilization Consent Form DMS-615 and checklist. 1. In the case of premature delivery, provided at least 72 hours have passed between giving the informed consent and performance of the sterilization procedure, and counseling and informed consent were given at least 30 days before the expected date of delivery. 2. In the case of emergency abdominal surgery, provided at least 72 hours have passed between giving informed consent and the performance of the sterilization procedure. F. The person is informed, before any sterilization discussion or counseling, that no benefits or rights will be lost because of refusal to be sterilized and that sterilization is an entirely voluntary matter. This should be explained again just before the sterilization procedure takes place. G. If the person is an individual with a physical disability and signs the consent form with an "X," two witnesses must also sign and include a statement regarding the reason the patient signed with an "X," such as stroke, paralysis, legally blind, etc. If a consent form is received that does not have the statement attached, the claim will be denied. H. A copy of the properly completed form DMS-615, with all items legible, must be attached to each claim submitted from each provider. Providers include RHCs, FQHCs, hospitals, physicians, anesthesiologists and assistant surgeons. It is the responsibility of the physician performing the sterilization procedure to distribute correct legible copies of the signed Sterilization Consent Form DMS-615 to the hospital, anesthesiologist and assistant surgeon. I. Sterilizations are covered only when informed consent is properly documented by means of the form DMS-615. 1. The checklist for form DMS-615 lists consent form items that DMS medical staff reviews to determine whether a sterilization procedure will be covered. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-615Checklist.doc"View or print Sterilization Consent Form DMS-615 and checklist. 2. Using the checklist will help ensure the submittal of a correct form DMS-615. J. The individual undergoing the procedure must receive, from the physician performing the procedure or the facility in which the sterilization procedure takes place, an identical copy of the completed consent form that he or she signed and dated. 218.000 Benefit Limits218.100 RHC Encounter Benefit Limits9-1-20A. There is no RHC encounter benefit limit for Medicaid beneficiaries under the age of twenty-one (21) in the Child Health Services (EPSDT) Program. B. A benefit limit of twelve (12) visits per state fiscal year (SFY), July 1 through June 30, has been established for beneficiaries aged twenty-one (21) and older. The following services are counted toward the twelve (12) visits per SFY benefit limit: 1. Physician visits in the office, patients home, or nursing facility; 2. Certified nurse-midwife visits; 3. RHC encounters; 4. Medical services provided by a dentist; 5. Medical services provided by an optometrist; and 6. Advanced nurse practitioner services. Global obstetric fees are not counted against the 12-visit limit. Itemized obstetric office visits are counted in the limit. The established benefit limit does not apply to individuals receiving Medication Assisted Treatment for Opioid Use Disorder when it is the primary diagnosis and rendered by a qualified X-DEA waivered provider. (HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/MAT_ICD-10_ProcCodes.doc"View ICD OUD Codes). Extensions of the benefit limit will be considered for services beyond the established benefit limit when documentation verifies medical necessity. Refer to Section 218.310 of this manual for procedures for obtaining extension of benefits. 218.200 Family Planning Benefit Limits218.210 Basic Family Planning Visit10-13-03The Basic Family Planning Visit benefit limit is one per state fiscal year. 218.220 Periodic Family Planning Visit10-13-03The Periodic Family Planning Visit benefit limit is three per state fiscal year (July 1 June 30). 218.230 Reserved12-18-15218.240 Contraception218.241 Prescription and Non-Prescription Contraceptives10-13-03Contraceptives are not benefit-limited, with the following exception. A. Implantable contraceptive capsule kits are limited to 2 per 5-year period per beneficiary. B. The benefit limit for removal of the kit is once within five years of the last implantation. 218.300 Extension of Benefits10-1-15RHC encounters count toward the 12 visits per SFY benefit limit. Arkansas Medicaid considers, upon written request, extending the RHC benefit for reasons of medical necessity. A. Extensions of family planning benefits are not available. B. Extensions of the RHC core service encounter benefit are automatic for certain diagnoses. The following diagnoses do not require a benefit extension request. 1. Malignant neoplasm HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_218.300_list_1.xls"(View ICD codes.) 2. HIV infection and AIDS HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_218.300_list_2.xls"(View ICD codes.) 3. Renal failure HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_218.300_list_3.xls"(View ICD codes.) 218.310 Benefit Extension Requests2-1-05A. Requests to extend the RHC core service encounter benefit must be mailed to Arkansas Foundation for Medical Care, Inc. (AFMC). HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print Arkansas Foundation for Medical Care, Inc. (AFMC) contact information. 1. AFMC will not accept benefit extension requests transmitted via electronic facsimile (FAX). 2. Benefit extension requests are considered only after a claim has been filed and denied because the benefit is exhausted. B. Submit with the request a copy of the Medical Assistance Remittance and Status Report reflecting the claims denial for exhausted benefits. Do not send a claim. C. AFMC reserves the right to request additional information as needed to process a benefit extension request. Failures to timely provide requested additional information will result in technical denials, reconsiderations of which are not available. D. AFMC must receive a benefit extension request within 90 calendar days of the date of the benefits-exhausted denial. 1. AFMC will consider extending benefits only when extended benefits are medically necessary and all required documentation is received timely. 2. Requests received after the 90-day deadline will not be considered. E. Correspondence regarding benefit extension requests and requests for reconsideration of denied benefit extension requests does not constitute documentation or proof of timely claim filing. 218.311 Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services, form DMS-67112-15-14A. Benefit extension requests will be considered only when the provider has correctly completed all applicable fields of the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services, form DMS-671. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-671.doc"View or print form DMS671. B. The date of the request and the signature of the providers authorized representative are required on the form. Stamped and electronic signatures are accepted. C. Dates of service must be listed in chronological order on form DMS-671. When requesting benefit extension for more than four encounters, use a separate form for each set of four encounters. D. Enter a valid ICD diagnosis code and a brief narrative description of the diagnosis. E. Enter the revenue code, modifier(s) when applicable and the applicable nomenclature. F. Enter the number of units (encounters) requested under the extension. 218.312 Documentation Requirements2-1-05Records supporting the medical necessity of extended benefits must be submitted with benefit extension requests and requests for reconsideration of denied benefit extension requests. A. Clinical records must: 1. Be legible and include records supporting the specific request 2. Be signed by the performing provider 3. Include clinical, outpatient and/or emergency room records for dates of service in chronological order 4. Include related diabetic and blood pressure flow sheets 5. Include current medication list for date of service 6. Include obstetrical record related to current pregnancy when applicable 7. Include clinical indication for laboratory and x-ray services ordered with a copy of orders for laboratory and X-ray services signed by the physician B. Laboratory and radiology reports must include: 1. Clinical indication for laboratory and x-ray services ordered 2. Signed orders for laboratory and radiology services 3. Results signed by the performing provider 4. Current and all previous ultrasound reports, including biophysical profiles and fetal non-stress tests when applicable 218.313 Provider Notification of Benefit Extension Determinations2-1-05AFMC will approve or deny a benefit extension requestor ask for additional informationwithin 30 calendar days. A. AFMC reviewers will simultaneously advise the provider and the beneficiary when a benefit extension request is denied. B. Provider notification of benefit extension approval includes: 1. The revenue code approved, 2. The total number of units approved for the revenue code, 3. The benefit extension control number and 4. The approved beginning and ending dates of service. C. A denial notification letter is signed by a member of the benefit extension reviewing staff. 218.314 Reconsideration of Benefit Extension Denials2-1-05A. Medicaid allows only one reconsideration of a denied benefit extension request. B. Reconsideration requests that do not include all required documentation will be automatically denied. C. Requests to reconsider benefit extension denials must be received by AFMC within 30calendar days of the date of the denial notice. When requesting reconsideration: 1. Return all previously submitted documentation and pertinent additional information to justify the medical necessity of additional services. 2. Include a copy of the NOTICE OF ACTION denial letter with the resubmission. 218.320 Appealing an Adverse Action2-1-05A. When the state Medicaid agency or its designee denies a benefit extension request, the beneficiary may appeal the denial and request a fair hearing. B. An appeal request must be in writing and must be received by the Appeals and Hearings Section of the Department of Human Services (DHS) within 30 days of the date on the provider notification denial letter from AFMC. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DHSAppealsHearings.doc"View or print the Department of Human Services, Appeals and Hearings Section contact information. 218.400 Benefit Limits for Other Ambulatory Services Encounters10-13-03A. Arkansas Medicaid has established benefit limits in each program in which an RHC may enroll to provide other ambulatory services. 1. Other ambulatory services are counted for benefit limit purposes in the program in which they are provided and covered. 2. The established benefit limits for each such program can be found in the "Benefit Limits" section in Section II of each program's provider manual or in official correspondence released since the most recent provider manual update. 3. Services provided as other ambulatory services are considered encounters for settlement purposes, but they do not count against the RHC core service encounter benefit limit. B. Provider manuals can be ordered from the Provider Enrollment Unit or downloaded from the Arkansas Medicaid website, HYPERLINK "https://medicaid.mmis.arkansas.gov/"https://medicaid.mmis.arkansas.gov/. Provider manuals ordered from Provider Enrollment include unincorporated official correspondence. When downloading a program's provider manual from the Medicaid website, download the program's official notices as well. See Section I of this manual to order provider manuals. 230.000 PRIOR AUTHORIZATION10-13-03Prior authorization is not applicable to RHC services. 240.000 REIMBURSEMENT10-13-03Rural Health Clinics (RHCs) are reimbursed in accordance with different reimbursement methodologies for dates of service before January 1, 2001, and dates of service on and after January 1, 2001, regardless of their fiscal year end or cost reporting period. Section 240.100 and its subsections describe the methodology in effect for dates of service before January 1, 2001. Section 241.000 describes the methodology effective for dates of service on and after January 1, 2001. 240.100 Reimbursement Methodologies for Dates of Service Before January 1, 2001 There are two reimbursement methodologies in place for dates of service before January 1, 2001: one for provider-based RHCs and one for independent (free-standing) RHCs. 240.110 Methods of ReimbursementProvider Based RHCs, for Dates of Service Before January 1, 2001 Provider-based Rural Health Clinics are reimbursed in the interim using a cost to charge ratio with a year end cost settlement for all RHC core and ambulatory services. The cost to charge ratio and the cost settlement are calculated using the applicable Medicare principals of reimbursement found in 42 CFR 413. Provider-based RHCs must report their costs on the cost report of the parent provider (e.g., hospital). Please follow cost report procedures for the parent provider. Medicaid reimburses Provider-based RHCs at 100% of reasonable cost. 240.120 Methods of ReimbursementIndependent RHCs, for Dates of Service Before January 1, 20014-1-07Independent (free-standing) RHCs are reimbursed at an interim rate with a year end cost settlement. The interim rate and cost settlements are calculated using the applicable Medicare principles of reimbursement found in 42 CFR 413. Independent (free-standing) RHCs are required to report their costs on the CMS-222-92 cost reporting form. Independent (free-standing) RHCs are reimbursed at 100% of reasonable cost for Rural Health Clinic services. Other ambulatory services and Medicare-Medicaid crossover claims are not cost reimbursed. Independent (free-standing) RHCs may bill for these services using the applicable procedure codes and provider identification numbers. Arkansas Medicaid pays the lesser of the amount billed or the Medicaid maximum. 241.000 Reimbursement Methodology for Dates of Service On and After January 1, 2001 In accordance with Section 1902(aa) of the Social Security Act as amended by the Benefits Improvement and Protection Act (BIPA) of 2000, effective for dates of service occurring January 1, 2001, and after, payments to Rural Health Clinics (RHCs) for Medicaidcovered services will be made using a prospective payment system (PPS) based on per visit compensation. A. The PPS per visit rate for each facility will be calculated based on 100 percent of the average of the facilitys reasonable costs for providing Medicaidcovered services as determined from audited Medicare cost reports with ending dates in calendar year 1999 and calendar year 2000. Reasonable costs are defined as those costs which are allowable under Medicare cost principles outlined in 42 CFR 413 with no lesser-of-costs-or-charges limits and no per-visit payment limit. Cost reports used for rate setting purposes must cover a fiscal period of at least a full six months. If a provider has more than one cost report period ending in the same calendar year, Arkansas Medicaid will use the most recent cost report to calculate rates. Adjustments to the Medicare RHC Program allowable costs per the cost report may be necessary due to differences with Medicaid Program covered services. B. PPS per visit rates will be calculated by adding the total audited allowable costs as determined from the 1999 and 2000 cost reports and dividing the total by the total audited visits for the same two periods. Allowable costs for each period used to set the initial PPS rate will include applicable adjustments in accordance with the Medicare Economic Index (MEI) for primary care services, an index compiled and published by the Centers for Medicare and Medicaid Services. Until audited cost report information is available, interim rates will be implemented as of January 1, 2001, at the average cost per visit as determined from the two most recent provider cost reports. Interim rates will be calculated by adding the two periods per visit costs and dividing the total by two. Interim rates will be retroactively adjusted to January 1, 2001, when audited cost report information becomes available and final rates are calculated. C. Each facilitys PPS per visit rate will be adjusted to account for increases or decreases in scope of services. A scope of services change is defined as: 1. An addition or deletion of an RHC-covered service, 2. A change in the magnitude, intensity, or character of currently offered RHCcovered services, 3. A change in State or Federal regulatory requirements, 4. A change due to relocation, remodeling, opening a new clinic site or closing an existing clinic site, 5. A change in applicable technologies and medical practices, or 6. A change due to recurring taxes, malpractice insurance premiums or workmens compensation insurance premiums that were not recognized and included in the base years rate calculation. D. The following examples of scope of services changes are offered as guidance to understanding their definition, not as a definitive and comprehensive delineation of that definition. 1. Examples of adding or deleting an RHC-covered service include adding or deleting dental services or mental health services. 2. Examples of changes in the magnitude, intensity, or character of currently offered RHC - covered services may include: a. Adding or deleting specialties or specialists (e.g., pediatrics, geriatric specialists) or b. Adding or deleting HIV services or chronic disease treatments. 3. Changes in State or Federal regulatory requirements may result in: a. Mandated revisions in the types of practitioners and professional personnel employed by the facility (including ratios of assistants or nursing staff to particular practitioners) or b. Changes in support service equipment or personnel, such as those related to lab and X-ray or other automated diagnostic services, subject to reasonable costs criteria identified at 42 CFR 413. 4. Item 4 in part C provides its own examples and needs no further explanation. 5. Examples of changes in applicable technologies and medical practices may include: a. Replacing obsolete computer systems or computer hardware, b. Automating medical records, c. Updating software or replacing obsolete software, d. Converting to wireless communications systems, or e. Updating or replacing obsolete diagnostic equipment (which may necessitate personnel changes), subject to reasonable costs criteria identified at 42 CFR 413. 6. Item 6 in part C provides its own examples and needs no further explanation. E. All requested PPS rate increases due to scope of services changes are subject to reasonable costs criteria identified at 42 CFR 413. F. Written requests for both cost increases and cost decreases due to scope of services changes must be submitted by the provider. The request must be submitted (postmarked) within 5 months after the end of the providers fiscal period. The request must identify the beginning date that the change occurred and include detailed descriptions, documentation and calculations of the changes and costs differences. G. In order to qualify for a PPS rate change, the scope of services changes must equal at least a 5% total difference in the allowable per visit cost as determined for the fiscal period and the changes must have existed during the last full 6 months of the fiscal period. Arkansas Medicaid will review the submitted documentation and will notify the provider within 90 days whether a PPS rate change will be implemented. If implemented, the PPS rate change will reflect the cost difference of the scope of service change and be effective as of the later of the first date that the scope of service changed or the beginning date of the fiscal period. PPS rate changes will also be made due to scope of service changes identified through an audit or review process. If this occurs, the effective date of the PPS rate change will be the later of the first date that the scope of services changed or the beginning date of the cost report period for which the changes should have been reported. H. Independent (free-standing) RHCs that do not have minimal 1999 and 2000 cost report periods (at least 6 months) or who enroll in Medicaid after 2000, will have their initial PPS per visit rate established at the average of the current rates of the three nearest independent RHCs with similar caseloads. Determination of the nearest facilities will be by map mileage. A final PPS per visit rate shall be established using the facilitys allowable costs as determined from the providers first two audited cost reports with reporting periods of at least a full six months. The final PPS rate will be made effective as of the first day after the providers second fiscal cost report period used for rate setting. I. Provider based RHCs that do not have minimal 1999 and 2000 cost report periods (at least six months) or who enroll in Medicaid after 2000 will have their initial PPS per visit rate established at the average of the current rates of the provider hospitals other enrolled RHCs with similar caseloads. Should a newly enrolled provider-based RHC be the only clinic operated by the hospital, the initial PPS rate shall be established at the average of the current rates of the three nearest provider - based RHCs with similar caseloads. Determination of the nearest facilities will be by map mileage. A final PPS per visit rate shall be established using the facilitys allowable costs as determined from the providers first two audited cost reports with reporting periods of at least a full six months. The final PPS rate will be made effective as of the first day after the providers second fiscal cost report period used for rate setting. J. Beginning July 1, 2001, interim rates, initial PPS rates and final PPS rates will be adjusted annually, as of July 1st of each year, by the Medicare Economic Index (MEI) for primary care services, an index compiled and published by the Centers for Medicare and Medicaid Services. Rate adjustments will be equal to the previous calendar years index percentage change. 242.000 Submitting Cost Reports Cost reports are due within 5 months following the end of the providers fiscal year or other cost-reporting period. Please forward the CMS-222-92 to the Division of Medical Services, Financial Activities Unit. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMSFinancialActs.doc"View or print Financial Activities Unit contact information. If Financial Activities does not receive the cost report by the 5-month deadline, DMS will notify the provider by letter that all payments will be suspended until the cost report is received. Suspension of a provider allows claims to be processed but a check will not be issued to the provider. The providers remittance statement will indicate a statement number rather than an internal check number. The suspensions will be in effect until the cost report is received. Continued failure to file a cost report will result in termination of the providers participation in the Program. 242.010 Fee Schedule12-1-12Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at HYPERLINK "https://medicaid.mmis.arkansas.gov/"https://medicaid.mmis.arkansas.gov/ under the provider manual section. The fees represent the fee-for-service reimbursement methodology. Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined. Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed. Information may be changed or updated at any time to correct a discrepancy and/or error. Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum. 243.000 Rate Appeal and/or Cost Settlement Appeal Process A provider may request reconsideration of a Program decision by writing to the Assistant Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a Program/Provider conference and will contact the provider to arrange a conference if needed. Regardless of the Program decision, the provider will be afforded the opportunity for a conference, if he/she so wishes, for a full explanation of the factors involved and the Program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the Program/Provider conference. If the decision of the Assistant Director, Division of Medical Services is unsatisfactory, the provider may then appeal the question to a standing Rate Review Panel established by the Director of the Division of Medical Services which will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Human Services (DHS) Management Staff, who will serve as chairman. The request for review by the Rate Review Panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The Rate Review Panel will meet to consider the questions(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services. 250.000 BILLING PROCEDURES251.000 Introduction to Billing7-1-20Rural Health Clinic providers who submit paper claims must use either the CMS-1450 claim form, which also is known as the UB-04 claim form, or the CMS-1500. A Medicaid claim may contain only one (1) billing providers charges for services furnished to only one (1) Medicaid beneficiary. Section III of this manual contains information about available options for electronic claim submission. 252.000 CMS-1450 (UB-04) Billing Procedures252.100 Revenue Codes10-13-03RHCs may use only these revenue codes when billing. Revenue Code Revenue Code Description520EncounterIndependent Rural Health Clinic521EncounterProvider-based Rural Health Clinic524Basic or Periodic Family Planning VisitIndependent Rural Health Clinic525Basic of Periodic Family Planning VisitProvider-based Rural Health Clinic 252.101 Billing Instructions for Family Planning Visits6-15-10Effective on and after April 30, 2010, all claims submitted from RHC providers for family planning visits are to use the following billing protocol, regardless of the date of service. No RHC family planning visits should be billed under the physicians provider number. The revised billing protocol will allow correct payment according to the benefit limit for eligible Arkansas Medicaid beneficiaries. Rural Health Clinic providers are to bill revenue codes 0524 (for Independent RHCs) and 0525 (for Provider-Based RHCs), as well as an applicable procedure code and modifier. Procedure code 99402 with modifier U9 will be used for the basic family planning visit, and 99401 with modifier U9 will be used for the periodic family planning visit. This is shown in the following table. RHC basic and periodic family planning visits are billable electronically and on paper claim forms. All family planning services require a primary diagnosis of family planning on the claim. Revenue CodeDescriptionProcedure CodeDescriptionModifier0524Basic or Periodic Family Planning Visit Independent RHC99401Periodic Family Planning VisitU90524Basic or Periodic Family Planning Visit Independent RHC99402Basic Family Planning VisitU90525Basic or Periodic Family Planning Visit Provider-Based RHC99401Periodic Family Planning VisitU90525Basic or Periodic Family Planning Visit Provider-Based RHC99402Basic Family Planning VisitU9 252.102 Billing Instructions for EPSDT and ARKids First-B Medical Screenings9-1-14Effective on or after April 30, 2010, all claims submitted by RHC providers for EPSDT and ARKids First-B medical screens performed by RHC personnel are to use the following billing protocol, regardless of the date of service. No screens should be billed under the physicians provider number. However, if the screens were billed earlier under the physicians provider number, do not re-bill. RHC providers are to bill the appropriate screen codes and modifiers. Each RHCs individual encounter rate will now be reimbursed when the RHC bills one of these medical screen procedure codes with the correct modifier(s). However, the encounter rate will only be reimbursed if the charge for the service submitted on the claim is greater than or equal to the RHCs encounter rate. The RHC will be reimbursed the lesser of the billed amount or their encounter rate. Example If an RHCs encounter rate is $75 and the RHC submits a screen claim with a billed amount of $85, the RHC will be reimbursed the lesser $75 encounter rate. If the same RHC submits a screen claim with a billed amount of $70, the RHC will be reimbursed the $70 lesser amount and not the encounter rate. Screens are billable electronically and on paper claims. For ARKids First-A (EPSDT) electronic billing, medical screens will require the electronic 837P with the special program indicator 01 in the header, along with the appropriate certification condition indicator and code. At the detail level, the procedure code will be billed with the EP modifier and the second modifier. For ARKids First-A (EPSDT) paper billing, providers will bill on the CMS-1500 claim form using the EP modifier and the second modifier. See the Physician provider manual for more information. For ARKids First-B (ARKids First) electronic billing, medical screens will require the 837P without the special program indicator (professional electronic claim) with no modifier except for newborn care procedures, which require a UA modifier. For ARKids First-B (ARKids First) paper billing, providers will bill on the CMS-1500 claim form with no modifier except for newborn care procedure codes, which require a UA modifier. See the ARKids First provider manual for more information. This billing protocol is shown in the following table. DescriptionProcedure CodeMod #1Mod #2EPSDT Periodic Complete Medical Screen (New Patient)99381EPU1EPSDT Periodic Complete Medical Screen (New Patient)99382EPU1EPSDT Periodic Complete Medical Screen (New Patient)99383EPU1EPSDT Periodic Complete Medical Screen (New Patient)99384EPU1EPSDT Periodic Complete Medical Screen (New Patient)99385EPU1EPSDT Periodic Complete Medical Screen (New Foster Care Patient)99381EPH9EPSDT Periodic Complete Medical Screen (New Foster Care Patient)99382EPH9EPSDT Periodic Complete Medical Screen (New Foster Care Patient)99383EPH9EPSDT Periodic Complete Medical Screen (New Foster Care Patient)99384EPH9EPSDT Periodic Complete Medical Screen (New Foster Care Patient)99385EPH9ARKids Complete Medical Screen (New Patient)99381ARKids Complete Medical Screen (New Patient)99382ARKids Complete Medical Screen (New Patient)99383ARKids Complete Medical Screen (New Patient)99384ARKids Complete Medical Screen (New Patient)99385EPSDT Periodic Complete Medical Screen (Established Patient)99391EPU2EPSDT Periodic Complete Medical Screen (Established Patient)99392EPU2EPSDT Periodic Complete Medical Screen (Established Patient)99393EPU2EPSDT Periodic Complete Medical Screen (Established Patient)99394EPU2EPSDT Periodic Complete Medical Screen (Established Patient)99395EPU2EPSDT Periodic Complete Medical Screen (Established Foster Care Patient)99391EPH9EPSDT Periodic Complete Medical Screen (Established Foster Care Patient)99392EPH9EPSDT Periodic Complete Medical Screen (Established Foster Care Patient)99393EPH9EPSDT Periodic Complete Medical Screen (Established Foster Care Patient)99394EPH9EPSDT Periodic Complete Medical Screen (Established Foster Care Patient)99395EPH9ARKids Complete Medical Screen (Established Patient)99391ARKids Complete Medical Screen (Established Patient)99392ARKids Complete Medical Screen (Established Patient)99393ARKids Complete Medical Screen (Established Patient)99394ARKids Complete Medical Screen (Established Patient)99395EPSDT Newborn Care/Screen in Hospital99460EPUAEPSDT Newborn Care/Screen in Hospital99461EPUAEPSDT Newborn Care/Screen in Hospital99463EPUANewborn Care/Screen in Hospital99460UANewborn Care/Screen in Hospital99461UANewborn Care/Screen in Hospital99463UA 252.103 Billing of Multi-Use and Single-Use Vials11-1-15Arkansas Medicaid follows the billing protocol per the Federal Deficit Reduction Act of 2005 for drugs. A. Multiple units may be billed when applicable. Take-home drugs are not covered. Drugs loaded into an infusion pump are not classified as take-home drugs. Refer to payable CPT code ranges 96365 through 96379. B. When submitting Arkansas Medicaid drug claims, drug units should be reported in multiples of the dosage included in the HCPCS procedure code description. If the dosage given is not a multiple of the number provided in the HCPCS code description the provider shall round up to the nearest whole number in order to express the HCPCS description number as a multiple. 1. Single-Use Vials: If the provider must discard the remainder of a single-use vial or other package after administering the prescribed dosage of any given drug, Arkansas Medicaid will cover the amount of the drug discarded along with the amount administered. 2. Multi-Use Vials: Multi-use vials are not subject to payment for any discarded amounts of the drug. The units billed must correspond with the units administered to the beneficiary. 3. Documentation: The provider must clearly document in the patients medical record the actual dose administered in addition to the exact amount wasted and the total amount the vial is labeled to contain. 4. Paper Billing: For drug HCPCS/CPT codes requiring paper billing (i.e., for manual review), complete every field of the DMS-664 Procedure Code/NDC Detail Attachment Form. Attach this form and any other required documents to your claim when submitting it for processing. Remember to verify the milligrams given to the patient and then convert to the proper units for billing. Follow the Centers for Disease Control (CDC) requirements for safe practices regarding expiration and sterility of multi-use vials. 252.110 Non-Payable Diagnosis Codes10-1-15The following ICD diagnosis codes are non-payable. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V57.1.xls"(View ICD codes.)Other physical therapyHYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V57.2.xls"(View ICD codes.)Occupational therapy and vocational rehabilitationHYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V57.3.xls"(View ICD codes.)Speech therapyHYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V72.5.xls"(View ICD codes.)Radiological examination, not elsewhere classifiedHYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V72.60.xls"(View ICD codes.)Laboratory examination 252.120 Diagnosis Codes not Covered for Beneficiaries under 2110-1-15The following ICD diagnosis codes are non-payable for beneficiaries under the age of 21. Refer to the Child Health Services (EPSDT) Provider Manual and the ARKids First-B Provider Manual for instructions regarding procedure and diagnosis coding on well childcare claims. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.0.xls"(View ICD codes.)Routine general medical examination at a health care facilityHYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.3.xls"(View ICD codes.)Other medical examination for administrative purposesHYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.5.xls"(View ICD codes.)Health examination of defined subpopulationsHYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.7.xls"(View ICD codes.)Examination for normal comparison or control in clinical researchHYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.9.xls"(View ICD codes.)Unspecified general medical examinationHYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V72.85.xls"(View ICD codes.)Other specified examination 252.200 Place of Service and Type of Service Codes10-13-03Not applicable to this program. 252.300 Billing InstructionsPaper Claims11-1-17Medicaid does not supply providers with Uniform Billing claim forms. Numerous venders sell CMS-1450 (UB-04 forms.) HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/SampleCMS-1450.doc"View a sample CMS-1450 (UB-04) claim form. Complete Arkansas Medicaid program claims in accordance with the National Uniform Billing Committee UB-04 data element specifications and Arkansas Medicaids billing instructions, requirements and regulations. The National Uniform Billing Committee (NUBC) is a voluntary committee whose work is coordinated by the American Hospital Association (AHA) and is the official source of information regarding CMS-1450 (UB-04.) HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AmericanHospAssoc.doc"View or print NUBC contact information. The committee develops, maintains and distributes to its subscribers the Official UB-04 Data Specifications Manual (UB-04 Manual) and periodic updates. The NUBC is also a vendor of CMS-1450 (UB-04) claim forms. Following are Arkansas Medicaids instructions for completing, in conjunction with the UB-04 Manual, a CMS-1450 (UB-04) claim form. Please forward the original of the completed form to the Claims Department. One copy of the claim form should be retained for your records. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/Claims.doc"View or print Claims Department contact information. NOTE: A provider furnishing services without verifying beneficiary eligibility for each date of service does so at the risk of not being reimbursed for the services. The provider is strongly encouraged to print the eligibility verification and retain it until payment is received. 252.310 Completion of CMS-1450 (UB-04) Claim Form12-15-14 Field #Field nameDescription1.(blank)Enter the providers name, (physical address service location) city, state, zip code, and telephone number.2.(blank)The address that the provider submitting the bill intends payment to be sent if different from FL 01. (Use this address for providers return address for returned mail.)3a.PAT CNTL #The provider may use this optional field for accounting purposes. It appears on the RA beside the letters MRN. Up to 16 alphanumeric characters are accepted.3b.MED REC #Required. Enter up to 15 alphanumeric characters.4.TYPE OF BILLType of Bill Enter the three digit numeric code found in the Data Specifications Manual to indicate the specific type of bill. 5.FED TAX NOThe number assigned to the provider by the Federal government for tax reporting purposes. Also known as tax identification number (TIN) or employer identification number (EIN).6.STATEMENT COVERS PERIODEnter the beginning and ending service dates of the period covered by this bill. To bill on a single claim for services occurring on multiple dates, enter the beginning and ending service dates in the FROM and THROUGH fields. The FROM and THROUGH dates may not span calendar months. When billing for multiple dates of service on a single claim, a date of service is required in field 45 for each HCPCS code in field 44 and/or each revenue code in field 42.7.Not usedReserved for assignment by the NUBC.8a.PATIENT NAMEEnter the patients last name and first name. Middle initial is optional.8b.(blank)Not required.9.PATIENT ADDRESSEnter the patients full mailing address. Optional.10.BIRTH DATEEnter the patients date of birth. Format: MMDDYYYY.11.SEXEnter M for male, F for female, or U for unknown.12.ADMISSION DATENot applicable.13.ADMISSION HRNot applicable.14.ADMISSION TYPENot applicable.15.ADMISSION SRCNot applicable.16.DHRNot applicable.17.STATNot applicable.18.-28.CONDITION CODESRequired when applicable. See the UB-04 Manual for requirements and for the codes used to identify conditions or events relating to this bill.29.ACDT STATENot required.30.(blank)Unassigned data field.31.-34.OCCURRENCE CODES AND DATESRequired when applicable. See the UB-04 Manual.35.-36.OCCURRENCE SPAN CODES AND DATESSee the UB-04 Manual.37.Not usedReserved for assignment by the NUBC.38.Responsible Party Name and AddressSee the UB-04 Manual.39.VALUE CODES Not required.a. CODENot applicable. AMOUNTNot applicable.b. CODENot applicable. AMOUNTNot applicable.40.VALUE CODESNot applicable.41.VALUE CODESNot applicable.42.REV CDEnter 0521 for an RHC Visit (encounter).43.DESCRIPTIONEnter the Revenue Codes corresponding Standard Abbreviation found in the UB-04 Manual. 44.HCPCS/RATE/HIPPS CODESee the UB-04 Manual.45.SERV DATEWhen the FROM and THROUGH dates indicate the claim is for multiple dates of service, enter the service (encounter) date for each revenue code. Always enter the service date of each HCPCS or CPT procedure code. Format: MMDDYY.46.SERV UNITSEnter the number of units furnished of each itemized service per date of service.47.TOTAL CHARGESThe total charge for the line-item number of units reported in field 46. See the UB-04 Manual for additional information.48.NON-COVERED CHARGESNot required.49.Not usedReserved for assignment by the NUBC.50.PAYER NAMELine A is required. See the UB-04 for additional regulations.51.HEALTH PLAN IDReport the HIPAA National Plan Identifier; otherwise report the legacy/proprietary number.52.REL INFORequired.53.ASG BENRequired. See Notes at field 53 in the UB-04 Manual.54.PRIOR PAYMENTSEnter the total of payments previously received on this claim. Do not include amounts previously paid by Medicaid. * Do not include in this total the automatically deducted Medicaid or ARKids First-B co-payments.55.EST AMOUNT DUESituational. See the UB-04 Manual.56.NPIEnter NPI of billing provider or enter the Medicaid ID. 57.OTHER PRV IDNot required.58. A, B, CINSUREDS NAMEComply with the UB-04 Manuals instructions when applicable to Medicaid.59. A, B, CP RELComply with the UB-04 Manuals instructions when applicable to Medicaid.60. A, B, CINSUREDS UNIQUE IDOn line A, enter the RHC patients Arkansas Medicaid or ARKids First (A or B) identification number on first line of field. 61. A, B, CGROUP NAMEUsing the plan name if the patient is insured by another payer or other payers, follow instructions for field 60.62. A, B, C INSURANCE GROUP NOWhen applicable, follow instructions for fields 60 and 61.63. A, B, CTREATMENT AUTHORIZATION CODESEnter any applicable prior authorization or benefit extension number on line 63A.64. A, B, CDOCUMENT CONTROL NUMBERField used internally by Arkansas Medicaid. No provider input.65. A, B, CEMPLOYER NAMEWhen applicable, based upon fields 51 through 62, enter the name(s) of the individuals and entities that provide health care coverage for the patient (or may be liable).66.DXDiagnosis Version Qualifier. See the UB-04 Manual. Qualifier Code 9 designating ICD-9-CM diagnosis required on claims. Qualifier Code 0 designating ICD-10-CM diagnosis required on claims. Comply with the UB-04 Manuals instructions on claims processing requirements.67. A-H(blank)Enter the ICD-9-CM or ICD-10-CM diagnosis codes corresponding to additional conditions that coexist at the time of admission, or develop subsequently, and that have an effect on the treatment received or the length of stay. Fields are available for up to 8 codes.68.Not usedReserved for assignment by the NUBC.69.ADMIT DXNot required.70.PATIENT REASON DXNot applicable.71.PPS CODENot required.72ECISee the UB-04 Manual. Required when applicable (for example, TPL and torts).73.Not usedReserved for assignment by the NUBC.74.PRINCIPAL PROCEDURE CODE AND DATE and OTHER PROCEDURE CODES AND DATESNot required.75.Not usedReserved for assignment by the NUBC.76.ATTENDING NPIEnter NPI of the primary attending physician or enter the Medicaid ID.QUALNPI not required.LASTEnter the last name of the primary attending physician.FIRSTEnter the first name of the primary attending physician.77.OPERATING NPINPI not required.QUALNot applicable.LASTNot applicable.FIRSTNot applicable.78.OTHER NPIEnter NPI of the primary care physician or enter the Medicaid ID.QUALNPI not required.LASTEnter the last name of the primary care physician.FIRSTEnter the first name of the primary care physician.79.OTHER NPI/QUAL/LAST/FIRSTNot used. 80.REMARKSFor providers use.81.Not usedReserved for assignment by the NUBC. 252.400 Special Billing Procedures9-1-20252.401 Upper Respiratory Infection Acute Pharyngitis9-1-20A Rural Health Center (RHC) must submit a claim that includes CPT code 87430, 87650, 87651, 87802, or 87880 in the Upper Respiratory Infection (URI)-Acute Pharyngitis episode if a strep test is performed when prescribing an antibiotic for beneficiaries. This allows DMS to determine if the Principle Accountable Provider (PAP) met or exceeded the quality threshold in order to qualify for a full positive supplemental payment for the URI-Pharyngitis episode. 252.402 Medication Assisted Treatment9-1-20When billing a claim for MAT the actual attending providers NPI must be entered on the claim.     Rural Health Clinic Section II Section II- PAGE 1  !*+,-[\]^cyz{|) * + , - H I J K R S h i j k ɵɟҟɏ~~n~~jh%Ph7$0JU hth7$CJOJPJQJaJjh%Ph7$0JU+hth7$5;B*CJOJQJaJphjh%Ph7$0JUh7$h%Ph7$0Jjh%Ph7$0JUjhiNhKKUhiNhKK5 hiNhKK hiNhU+!*+,+ j  M 4 lkd$$Ifl40N$$ @@ss4 l` saf4pssyt=!6 $IfgdU$Ifk l v      ! " ) * F K L M N O j k l m t u jh%Ph7$0JUjh%Ph7$0JUj h%Ph7$0JUjh%Ph7$0JU hth7$CJOJPJQJaJjh%Ph7$0JUjh%Ph7$0JUh7$h%Ph7$0J4 2 3 4 5 6 Q R S T [ \ ُjh%Ph7$0JU+hth7$5;B*CJOJQJaJphjqh%Ph7$0JUjh%Ph7$0JUj{h%Ph7$0JUh7$jh%Ph7$0JUh%Ph7$0J hth7$CJOJPJQJaJ2 E  5W%v5~RQ$     ! " C D E F G b c d e l m      ! " # * + jSh%Ph7$0JUjh%Ph7$0JUj]h%Ph7$0JUjh%Ph7$0JU hth7$CJOJPJQJaJjgh%Ph7$0JUh7$h%Ph7$0Jjh%Ph7$0JU4   34567RSTU\]e !")*UVWXYZtuj? h%Ph7$0JUj h%Ph7$0JUjI h%Ph7$0JUjh%Ph7$0JUh7$jh%Ph7$0JU hth7$CJOJPJQJaJh%Ph7$0J7uvw~ #$%&'4BCDELMtuvwxٴ٤ٔلj h%Ph7$0JUj+ h%Ph7$0JUj h%Ph7$0JUj5 h%Ph7$0JUh7$ hth7$CJOJPJQJaJh%Ph7$0Jjh%Ph7$0JUj h%Ph7$0JU4  34567RSTU\]|}~j h%Ph7$0JUjh%Ph7$0JUjh%Ph7$0JUj h%Ph7$0JU hth7$CJOJPJQJaJj! h%Ph7$0JUh7$h%Ph7$0Jjh%Ph7$0JU4 PQRSTopqryz67jh%Ph7$0JUj~h%Ph7$0JUjh%Ph7$0JUjh%Ph7$0JUh7$jh%Ph7$0JUh%Ph7$0J hth7$CJOJPJQJaJ4789@AOPQRSnopqxy"#$%&ABCDKLjklٴ٤ٔلj`h%Ph7$0JUjh%Ph7$0JUjjh%Ph7$0JUjh%Ph7$0JUh7$ hth7$CJOJPJQJaJh%Ph7$0Jjh%Ph7$0JUjth%Ph7$0JU4$l/nC@#ZNCQo0ulmn-./01LMNOVWXlmnopjh%Ph7$0JUjLh%Ph7$0JUjh%Ph7$0JUjVh%Ph7$0JU hth7$CJOJPJQJaJjh%Ph7$0JUh7$h%Ph7$0Jjh%Ph7$0JU4ABCDEY`abcjk  >?@AB]^jh%Ph7$0JUj8h%Ph7$0JUjh%Ph7$0JUjBh%Ph7$0JUh7$jh%Ph7$0JU hth7$CJOJPJQJaJh%Ph7$0J8^_`gh !"#$%@ABCJKXYZ[\wxٴ٤َ~َjh%Ph7$0JU+hth7$5;B*CJOJQJaJphj$h%Ph7$0JUjh%Ph7$0JUh7$ hth7$CJOJPJQJaJh%Ph7$0Jjh%Ph7$0JUj.h%Ph7$0JU,xyzLMNOPklmnuvABCDE`abcjkٴ٤ٔلjh%Ph7$0JUjh%Ph7$0JUjh%Ph7$0JUjh%Ph7$0JUh7$ hth7$CJOJPJQJaJh%Ph7$0Jjh%Ph7$0JUjh%Ph7$0JU4'2345<=OPQRSnopqxyٵ٥ُjh%Ph7$0JU+hth7$5;B*CJOJQJaJphjwh%Ph7$0JUjh%Ph7$0JUjh%Ph7$0JUh7$h%Ph7$0Jjh%Ph7$0JU hth7$CJOJPJQJaJ23456;=>mnopq./0ٴ٤ٔلjY h%Ph7$0JUjh%Ph7$0JUjch%Ph7$0JUjh%Ph7$0JUh7$ hth7$CJOJPJQJaJh%Ph7$0Jjh%Ph7$0JUjmh%Ph7$0JU4012=MNOPWXstuvw'()*+FGHIPQrstuvj"h%Ph7$0JUjE"h%Ph7$0JUj!h%Ph7$0JUjO!h%Ph7$0JU hth7$CJOJPJQJaJj h%Ph7$0JUh7$h%Ph7$0Jjh%Ph7$0JU4u)t d< ~u $Ifgd`Qkkd$$$Ifl40N$$ @@ss4 laf4pssyt=!6 $Ifgd5$If"gd5      ()*+23abcdef < E F W !@!W!٫﫫٫ hiNhy hiNhKKjhiNhKKUj1$h%Ph7$0JU *h%Ph7$0Jj#h%Ph7$0JUj;#h%Ph7$0JUh7$jh%Ph7$0JUh%Ph7$0J hth7$CJOJPJQJaJ3< E F @!R"p"x"~yyl_ $IfYD<gdg $IfYD<gdggdywkd<%$$Ifl40N$$04 laf4yt=!6 $Ifgd`QW!"Q"R"W"p"x"y"""""#(#1#2#W#$#$F$M$N$Q$W$$$$%!%(%)%W%z%%%%%%&'&W&'W''(W()W)*W*z*{****+ + + +ĹĮhiNh(0Jj(hiNhUhjhiNh(UhiNh(0JCPJ hiNh( hiNh7z* hiNh5 hiNhKKhiNh 4hPJaJ hiNhw hiNh 4h hiNhy:x"y""(#1#yp $Ifgd5 $Ifgd5gd 4hwkd%$$Ifl40N$$04 laf4ytg1#2##$F$M$|s $Ifgd5 $Ifgd5gd5tkd&$$Ifl40N$$04 laf4M$N$$$!%(%x $IfgdK $IfgdKgd5okd'$$Ifl40N$$04 laf4(%)%z%%%}xof $Ifgd( $Ifgd(gd7z*kd'$$Ifl40N$$FF t044 lBaf4ytK%%'&'U,.7.@.{vvvqh_ $Ifgd?V $Ifgd?Vgd(gdkzkdM($$Ifl40N$$FF t0$644 lBaf4ytkz + +d+e+f++++++, ,,,S,T,U,,,-^-_----.....7.@.A...///4/d///////00B0000011122&2b2k2l22ү hiNhKKhiNh:PJ hiNh:j2,hiNhUj+hiNhU hiNh(hiNh(0Jj)hiNhUhjhiNh(U>@.A./4/d//////B000}}}}}}}}tk $Ifgd)w $Ifgd)wgd:gd:wkdK-$$Ifl40N$$04 laf4yt?V 00&2b2k2|s $Ifgd)w $Ifgd)wgd)wtkd-$$Ifl40N$$04 laf4k2l2B445/5=5O5f555C66"7^7gd)wgd)wgd)wokd}.$$Ifl40N$$04 laf4233344B44445555/525=5@5O5R5f5i55555566C6F666677"7%7^77777888888888889,9999999999:,::;;,;;<ݾ hiNh&hiNhKK0Jj/hiNh0JU h0JjhiNhKK0JUhiNhKK5 hiNh)w hiNhKKH^789999999vmd $Ifgdfn $Ifgdfnkkd,0$$Ifl40N$$ @@ss4 laf4pssyt=!6 $Ifgd)w $Ifgd)w"gd)wgd)w99;<w<>>>}}}tk $Ifgd)w $Ifgd)wgd&gd&wkd0$$Ifl40N$$04 laf4yt=!6<<,<w<<=,==>,>>>>>>>?%?&??????@ @`@l@s@@@@@@@@@@@@@AAAA)A,A>A?A@AUAVAYAAAAAAAAAAAAAAABBBCBDBTBUBBBB *h0qhiN *h/hiN *hV]hiNhiN *h/hiN h*`hiN hiNhiN hiNhKK hiNh&L>>&? @`@AVAAABC'DJE1F{{{{vv?gdiNgdiNgdiNgdiNtkdf1$$Ifl40N$$04 laf4 BBBBBBBBBBCHCICfCgCCCCCCCCCD%D'D,D-D4D5DDDDE4E5EIEJEOEPEEEEEEF*F+F0F1F4F`FiFqFFFFFFGGŵ *h`1hiN5 *h\O5 *h`1hiNh*`hiN6 *h]hiN *hi?}hiN *h.mhiN *h&ehiN *h+hiN *h0qhiN h*`hiN *h/hiNhiN<G*G5G6GGGGGGGHHHHHbHkHlHHHHIIIIbIeIIIIJ J JJJJJKKPKYKZKKKKLLLLhLkLLLLMMMMMNNNNNOOOO}OOOOOPPIPPQQQRR)RYRbR hiNh: hiNh)w hiNhKK hiNh. *h`1hiN *hiNT1FGHHHbHkHxokd1$$Ifl40N$$04 laf4 $Ifgd)w $Ifgd)wgdiNkHlHHIbII JJJPKYKwn $IfgdW_ $IfgdW_gd:gd)wgd)wokd2$$Ifl40N$$04 laf4 YKZKKLhLLMNO}OOO|s $IfgdW_ $IfgdW_gd:gdW_okd(3$$Ifl40N$$04 laf4 OOIP)RYRbR|s $IfgdW_ $IfgdW_gdW_tkd3$$Ifl40N$$04 laf4bRcRRRSS#S,S-SSTTiTTTTTUUUUUUUUVVV VXV[VvVyVVVVWWWWRWUWWXXXXXYY=Y@YYZZ8ZoZZZZ[[[[[[\\\\\]]V]]]^^^^___hiNh*`OJQJ hiNh*`hiNhKK5 hiNhW_ hiNhb/ hiNhKKRbRcRR#S,Sx $Ifgd8l $Ifgd8lgdW_okdT4$$Ifl40N$$04 laf4,S-SiTTTxo $IfgdW_ $IfgdW_gdb/ykd4$$Ifl40N$$0$64 laf4yt8lTTUUU|s $IfgdW_ $IfgdW_gdW_tkd5$$Ifl40N$$04 laf4UUVXVvVVWRWX=YZ[\\|s $Ifgd*` $Ifgd*`gdW_gdW_okd6$$Ifl40N$$04 laf4 \\V]]^`,aaaHbbNckc}xxxxxxssssj $Ifgdfngd*`gd*`kd6$$Ifedyl40N$$FF t0$644 lBaf4ity _````aa,aaaabbHbbbccMcNckcrcsccdd0d:dudddddeeeeeeefffffggggghhhh3h6hhiiiiqitiijj9j* hiNh& hiNh*`Tkcrcscuddd~ypg $IfgdW_ $IfgdW_gd&wkd]7$$Ifl40N$$0$4 laf4ytfn $Ifgdfnddeee|s $IfgdW_ $IfgdW_gdW_tkd7$$Ifl40N$$04 laf4eefgh3hiqi9jPjjk0kw $IfgdW_gdW_gdW_tkd8$$Ifl40N$$04 laf4 0k1k2kQkZk} $IfgdW_okd%9$$Ifl40N$$04 laf4 $IfgdW_Zk[kk*llll|s $Ifgdfn $Ifgdfngd:gdW_okd9$$Ifl40N$$04 laf4kkkll*l-llllllllmmsmmmmmmnnBnenxnnnnno oo@oAoBojosotooooppppQpTppppppqqqq8q;qqqqqqqqqqqrrrrrrrss.s7shiNhZ0J@ hiNhZ hiNhW_hiNh&5 hiNh& hiNhKK hiNh:PlllsmmmmmBnenxnnnn}}xxx}}xxxxgd&gd&gd&wkdQ:$$Ifl40N$$0$4 laf4ytfn n oBojosotoopQpppnid__dgdW_gdW_gdW_tkd:$$Ifl40N$$04 laf4 $IfgdW_ $IfgdW_gd&gd& pq8qqqqqrrrsf] $IfgdW_ h^h`gdZtkd;$$Ifl40N$$04 laf4 $IfgdZ $IfgdW_gdW_ rr.s7sx $IfgdW_ $IfgdW_tkd<$$Ifl40N$$04 laf47s8s;sssstthiNh0JU h0JjhiNhe0JU hiNhe hiNhW_ hiNhKKL7s8ss?Cߡ?C\_ߢ?CX[ϣңߣ?C_bߤ?Cf֥ߥ?Cɦʦ޿򸸸jhiNhi0JU hiNhihiNh$30JjNhiNh0JU h0JjhiNh$30JU hiNh_E hiNh$3 hiNhRC ?ܠ;\Xϣ_f֥ߥ{{{{ri $Ifgd $Ifgdgd$3gd_Egd_EtkdM$$Ifl40N$$04 laf4 ߥ6ڧLzqh $Ifgd_E $Ifgd_Egd gdi{kdO$$Ifl4K0N$$0$64 laf4yt 456jnڧ jn LjnjnwzӪ֪ehjn׫ګ"%jn.1ehjn MNUVj˻˻hiNh$3PJ hiNh_E hiNh$3 hiNhihiNhi0JjhiNhi0JUjOhiNh0JUJwӪe׫".e}xxxxxxxsxxgd$3gd_Egd_Egd_ExkdP$$Ifl4K0N$$0$64 laf4 e NUVǮAܯrmhcgd$3gd_Egd_EvkdQ$$Ifl40N$$0$64 laf4 $Ifgd_E $Ifgd_Egd_E jnǮʮADjnܯ߯ ?Bjn԰۰ܰ߰/2jnAjnвCJKNjnjn2|}~ξԵhiNh$30JjThiNh0JU h0JjhiNh$30JUhiNh$35 hiNh$3 hiNh_EhiNh$3PJD?԰۰ܰ/AвCkfffgd_ExkdR$$Ifl4K0N$$0$64 laf4 $Ifgd_E $Ifgd_Egd$3gd_E CJK~ǵzzqh $Ifgd_E $Ifgd_Egd_EtkdGS$$Ifl40N$$04 laf4 $$Ifgd$3~ǵȵ˵2MPȶ˶22cfѸԸڸ۸ /06չع6HIenoƺǺ6666hiNhKK>*jUhiNh 0JU h 0JjhiNhKK0JU hiNh% hiNh_E hiNhKKLǵȵMȶcHIen~ypg $Ifgd_E $Ifgd_E"gd_Egd_Egd_Etkd*U$$Ifl40N$$04 laf4 noƺy $Ifgd_E $Ifgd_E"gd_ElkdV$$Ifl40N$$ @@ss4 l` saf4pssyt=!6ƺǺ;'v $Ifgdp  $Ifgdp gd_Egd_Elkd.W$$Ifl40N$$ @@ss4 l` saf4pssyt=!6 6;'66v6O666BE6666666sv6GJ hiNh hiNh_E hiNhk` hiNhKKhiNhKK>*VvOBsGJ{vvvqqqqgdgd_Egd_Egd_Egdk`tkdW$$Ifl40N$$04 laf4 6JM6FJ6~6WZ66]`6AD`c6kn6DG66666 hiNh hiNhKK`JF~W]A`kDENgdgdgdgd6666666EH66NBCD```ݾ hiNh[DhiNhKK0JjaXhiNh0JU h0JjhiNhKK0JUhiNhKKH* hiNh hiNhKKHNDl=jeee`gdgd[D}kdY$$Ifl40N$$0$644 laf4ytU $IfgdU $IfgdUgd !BPQRuvdldddd=dddd MTd hiNh2y hiNhe hiNhKK h5~0Jj@ZhiNh5~Uh5~jhiNh[DU hiNh[DL xof $Ifgde $Ifgdekkd[$$Ifl40N$$ @@ss4 laf4pssyt=!6 $Ifgd $Ifgd"gdgd /{{vmd $Ifgd $Ifgdgd2y  & Fh^hgd*Swkd[$$Ifl40N$$04 laf4yt`/de()BCGdqrv(@ABdz(d(PTdpu#(79d(VWdhiNhU)PJhiNhU)5 hiNhU) hiNh: hiNhGg hiNhKK hiNh2yPx $Ifgd $IfgdtkdK\$$Ifl40N$$04 laf4(Bww $Ifgd:"gd:gdtkd\$$Ifl40N$$04 laf4BCGq$Ifqkdw]$$Ifl440o2$Xk04 laf4qrv$Ifokd#^$$Ifl40o2$Xk04 laf4$Ifokd^$$Ifl40o2$Xk04 laf4@$Ifokdu_$$Ifl40o2$Xk04 laf4@ABzx $IfgdB $IfgdB"gdokd`$$Ifl40o2$Xk04 laf4VWdp|jjjjj$&`#$/IfgdU)"gdU)gdU)ykd`$$Ifl40N$$0$64 laf4ytB dp(8>Z]^cd (),-.d{(d (d(d(d(Wd(d(]dhiNh\5 hiNh\ hiNhU)hiNhU)CJaJhiNhU)PJTL:::::$&`#$/IfgdU)kda$$IflIr8! " 6` "644 lap2ytU)8>Z]L:::::$&`#$/IfgdU)kdib$$Iflr8!&& &"&& 6` "644 lap2ytU)]^cL:::::$&`#$/IfgdU)kdBc$$Iflr8!&& &"&& 6` "644 lap2ytU) ),L:::::$&`#$/IfgdU)kdd$$Iflr8!&& &"&& 6` "644 lap2ytU),-.{LG>5 $IfgdJ $Ifgd !p"gdU)kdd$$Iflr8!&& &"&& 6` "644 lap2ytU)W]E|}|ssss $IfgdU)"gdU)gd\ykde$$Ifl40N$$0$64 laf4ytW (d(Ed|}#$&'()*+_`defhiklm(1278:;=>?dhiNhU)aJhiNhU)PJaJhiNhU)CJaJhiNhU)PJ hiNhU) hiNh\P{rrrr $IfgdU)kdf$$Ifl4\#F* t!44 la.gytU)$'*}tttt $IfgdU)kd.g$$Ifl(\#''F'*' t!44 la.gytU)*+`fil}tttt $IfgdU)kdg$$Ifl(\#''F'*' t!44 la.gytU)lm}tttt $IfgdU)kddh$$Ifl(\#''F'*' t!44 la.gytU)}tttt $IfgdU)kdh$$Ifl(\#''F'*' t!44 la.gytU)28;>}tttt $IfgdU)kdi$$Ifl(\#''F'*' t!44 la.gytU)>?}tttt $IfgdU)kd5j$$Ifl(\#''F'*' t!44 la.gytU)d!"$%'()dijoprsuvw(FKLMNOd|       ( V \ _ hiNhU)aJhiNhU)PJaJ]}tttt $IfgdU)kdj$$Ifl(\#''F'*' t!44 la.gytU)"%(}tttt $IfgdU)kdkk$$Ifl(\#''F'*' t!44 la.gytU)()jpsv}tttt $IfgdU)kdl$$Ifl(\#''F'*' t!44 la.gytU)vw}tttt $IfgdU)kdl$$Ifl(\#''F'*' t!44 la.gytU)}tttt $IfgdU)kdAX~ytkk $Ifgd/@"gdYygdYywkd}$$Ifl40N$$04 laf4yt/@ $Ifgd/@XY $Ifgd/@rkd$$Ifl40o2$Xk04 laf4yt/@q $Ifgd/@rkdd$$Ifl40o2$Xk04 laf4yt/@]^opq&'(34i{"|   Nijk|}~j?hiNh0JUjDžhiNh0JUjhiNh0JU h0J hiNhYyhiNhYy0JjhiNhYy0JUD& $Ifgd/@rkd>$$Ifl40o2$Xk04 laf4yt/@&' $Ifgd/@rkd$$Ifl40o2$Xk04 laf4yt/@~u $IfgdYy $IfgdYy"gdYyrkd$$Ifl40o2$Xk04 laf4yt/@  ~}tt $Ifgd/@"gdYygdYywkd$$Ifl40N$$04 laf4yt/e~~ $Ifgd/@wkdj$$Ifl40o2$Xk04 laf4yt/@-./2efgnrs5Hcdevwx}+,-9=UVWbcټ٬ٜjhiNh0JUj͍hiNh0JUjhiNh0JU h0J hiNhYyhiNhYy0JjhiNhYy0JUjhiNh0JU;ef~~ $Ifgd/@wkdD$$Ifl40o2$Xk04 laf4yt/@x~~ $Ifgd/@wkd$$Ifl40o2$Xk04 laf4yt/@-U~~ $Ifgd/@wkd$$Ifl40o2$Xk04 laf4yt/@UV~~ $Ifgd/@wkdҐ$$Ifl40o2$Xk04 laf4yt/@#$D_cnvw,/?@Aklm / ?    !!!!'!S!ıyıhiNhUY0J*jhiNh5>*B*Uphh5>*B*phhiNhUY5>*B*ph$jhiNhUY5>*B*Uph hiNhUY hiNhKK hiNhYyhiNhYy0JjhiNhYy0JUjhiNh0JU/#yp $Ifgd $Ifgd"gdYywkd$$Ifl40o2$Xk04 laf4yt/@#$Dnv|s $Ifgd $Ifgdgdtkd]$$Ifl40N$$04 laf4vwm? !g""#%I%R%{{{{{{ri` $Ifgd $Ifgd?^gdU\  & Fh^hgdUYwkd$$Ifl40N$$04 laf4yt S!Y!i!j!k!!!!!!""Y"g""""##Y#y#z###########$G$$$$%%%F%H%I%R%S%T%\%g%s%t%w%ȿȸ hiNhQ`& hiNhi hiNhej˖hiNh0JU h0JjhiNhUY0JU hiNhUYhiNhUY0J$jhiNhUY5>*B*Uph*jhiNh5>*B*UphhiNhUY5>*B*ph2R%S%T%\%g%s%yyy $IfgdbA4"gdQ`&wkd֗$$Ifl40N$$0$4 laf4ytfns%t%w%%%sfff  & F$IfgdbA4kdr$$Ifl44Fo}$ 0!    4 laf4ytbA4w%%%%%%%%%%&F&&&&&&&&&'F'S'T'X'b'''''''''''(%(&()(4(F(((((((())F)))))* *F*********++++F+\+]+a+i+w+x+{++++++++++,,, ,,@,A,E,hiNhQ`&6 hiNhQ`&_%%%%&tggg  & F$IfgdbA4kd8$$Ifl4Fo}$ 0!    4 laf4ytbA4&&&&S'tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4S'T'X'b''tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4'''''%(tgggg  & F$IfgdbA4kdo$$Ifl4Fo}$ 0!    4 laf4ytbA4%(&()(4((tggg  & F$IfgdbA4kd,$$Ifl4Fo}$ 0!    4 laf4ytbA4((() **tgggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4****+uhhh  & F$IfgdbA4kd$$IflzFo}$ 0!    4 laytbA4++++\+tggg  & F$IfgdbA4kdo$$Ifl4Fo}$ 0!    4 laf4ytbA4\+]+a+i+w+tggg  & F$IfgdbA4kd,$$Ifl4Fo}$ 0!    4 laf4ytbA4w+x+{+++tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4++++,tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4,, ,,@,tggg  & F$IfgdbA4kdq$$Ifl4Fo}$ 0!    4 laf4ytbA4@,A,E,T,d,tggg  & F$IfgdbA4kd.$$Ifl4Fo}$ 0!    4 laf4ytbA4E,F,T,d,e,i,v,,,,,,,,,,,,,,,,,,,,,-- --F-----------------..>.?.F.G.g.}.~.............../////(/)/*/2/B/C/F/L/\/]/^/f/v/w/{//hiNhQ`&h7zGhiNhQ`&^J hiNhQ`&[d,e,i,v,,tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4,,,,,tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4,,,,,tggg  & F$IfgdbA4kde$$Ifl4Fo}$ 0!    4 laf4ytbA4,,,,,tggg  & F$IfgdbA4kd"$$Ifl4Fo}$ 0!    4 laf4ytbA4,,,,-tggg  & F$IfgdbA4kdߥ$$Ifl4Fo}$ 0!    4 laf4ytbA4-- ---tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4-----tgg^ $IfgdbA4  & F$IfgdbA4kdY$$Ifl4Fo}$ 0!    4 laf4ytbA4-----tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4---.>.tggg  & F$IfgdbA4kdӨ$$Ifl4Fo}$ 0!    4 laf4ytbA4>.?.G.g.}.tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4}.~....tggg  & F$IfgdbA4kdM$$Ifl4Fo}$ 0!    4 laf4ytbA4.....tggg  & F$IfgdbA4kd $$Ifl4Fo}$ 0!    4 laf4ytbA4...//tggg  & F$IfgdbA4kdǫ$$Ifl4Fo}$ 0!    4 laf4ytbA4////(/tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4(/)/*/2/B/tgg^ $IfgdbA4  & F$IfgdbA4kdA$$Ifl4Fo}$ 0!    4 laf4ytbA4B/C/F/L/\/tgg^ $IfgdbA4  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4\/]/^/f/v/tgg^ $IfgdbA4  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4v/w/{///tgg^ $IfgdbA4  & F$IfgdbA4kdN$$Ifl4Fo}$ 0!    4 laf4ytbA4/////////////////0F0W0X0\0r0000000001*1F1m1}1~1111111112F2l2m2q222222222222223333(3F33333333333333334F4j4n444444444hiNhQ`&5 hiNhQ`&_/////tgg^ $IfgdbA4  & F$IfgdbA4kd $$Ifl4Fo}$ 0!    4 laf4ytbA4/////tggg  & F$IfgdbA4kdְ$$Ifl4Fo}$ 0!    4 laf4ytbA4////W0tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4W0X0\0r00tggg  & F$IfgdbA4kdP$$Ifl4Fo}$ 0!    4 laf4ytbA40000*1m1}1tggggg  & F$IfgdbA4kd $$Ifl4Fo}2$ 0    4 laf4ytbA4}1~1111tggg  & F$IfgdbA4kdʳ$$Ifl4Fo}2$ 0    4 laf4ytbA41111l2tggg  & F$IfgdbA4kd$$Ifl4Fo}2$ 0    4 laf4ytbA4l2m2q222tggg  & F$IfgdbA4kdD$$Ifl4Fo}2$ 0    4 laf4ytbA422222tggg  & F$IfgdbA4kd$$Ifl4Fo}2$ 0    4 laf4ytbA422223tggg  & F$IfgdbA4kd$$Ifl4Fo}2$ 0    4 laf4ytbA4333(33tggg  & F$IfgdbA4kd{$$Ifl4Fo}2$ 0    4 laf4ytbA433333tggg  & F$IfgdbA4kd8$$Ifl4Fo}2$ 0    4 laf4ytbA433333tggg  & F$IfgdbA4kd$$Ifl4Fo}2$ 0    4 laf4ytbA433334tggg  & F$IfgdbA4kd$$Ifl4Fo}2$ 0    4 laf4ytbA444444tggg  & F$IfgdbA4kdo$$Ifl4Fo}$ 0!    4 laf4ytbA44555?5@5A5B5F5S5`5a5b5n5}5555555556"6#6/6C6F66666666667F7J7K7X7k7777777778#8$808F8H8888888889F9L9M9Q9T99999999::F:c:d:l:t: hiNh*hiNhQ`&^JhiNhePheP hiNheP hiNhQ`&U4555A5tggg  & F$IfgdbA4kd,$$Ifl4Fo}$ 0!    4 laf4ytbA4A5B5F5S5a5tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4a5b5n5}55tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA45555"6tggg  & F$IfgdbA4kdc$$Ifl4Fo}$ 0!    4 laf4ytbA4"6#6/6C66tgg^ $IfgdbA4  & F$IfgdbA4kd $$Ifl4Fo}$ 0!    4 laf4ytbA46666J7tggg  & F$IfgdbA4kdݾ$$Ifl4Fo}$ 0!    4 laf4ytbA4J7K7X7k77tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA47777#8tggg  & F$IfgdbA4kdW$$Ifl4Fo}$ 0!    4 laf4ytbA4#8$808H88tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA48888L9tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4L9M9Q9T999:c:tgggggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4c:d:l:t:|;tggg  & F$IfgdbA4kdK$$Ifl4Fo}$ 0!    4 laf4ytbA4t:::::;F;|;};;;;;;;;;;;;;;;;;;<<<<<F<c<d<h<q<<<<<<<<<<<<="=#='=5=F={=|=}=~==============>>>>(>9>:>;><>A>F>Q>R>S>X>h>i>j>p>>>>>hiNhQ`&^J hiNheP hiNhQ`&\|;};;;;tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4;;;;;tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4;;;;;tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4;;;<<tggg  & F$IfgdbA4kd?$$Ifl4Fo}$ 0!    4 laf4ytbA4<<<<c<tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4c<d<h<q<<tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4<<<<<tggg  & F$IfgdbA4kdv$$Ifl4Fo}$ 0!    4 laf4ytbA4<<<<"=tggg  & F$IfgdbA4kd3$$Ifl4Fo}$ 0!    4 laf4ytbA4"=#='=5=|=tggZ  & F$IfgdeP  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4|=}=~===tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4=====tggg  & F$IfgdbA4kdx$$Ifl4Fo}$ 0!    4 laf4ytbA4====>tggg  & F$IfgdbA4kd'$$Ifl4Fo}$ 0!    4 laf4ytbA4>>>(>:>tgg^ $IfgdbA4  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4:>;><>A>Q>tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4Q>R>S>X>h>tggg  & F$IfgdbA4kdB$$Ifl4Fo}$ 0!    4 laf4ytbA4h>i>j>p>>tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4>>>>>tggZ $If^gdbA4  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4>>>>>>>>>>>>>>>?$?%?&?,?F?`?a?e????????????????@@ @ @ @@@@@/@0@1@7@B@C@D@G@I@J@K@]@@@@@@@@AAAAA]AAAAAAB *h, *h/h, h,h, hiNh\5 hiNh&hiNhQ`&^J hiNheP hiNhQ`&N>>>>>tggg  & F$IfgdbA4kdO$$Ifl4Fo}$ 0!    4 laf4ytbA4>>>>$?tggg  & F$IfgdbA4kd $$Ifl4Fo}$ 0!    4 laf4ytbA4$?%?&?,?`?tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4`?a?e???tggg  & F$IfgdbA4kdj$$Ifl4Fo}$ 0!    4 laf4ytbA4?????tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4?????tggg  & F$IfgdbA4kd$$Ifl4Fo}$ 0!    4 laf4ytbA4???@ @tof] $IfgdQ $IfgdQ"gdQ`&kd$$Ifl4Fo}$ 0!    4 laf4ytbA4 @ @C@J@~u $IfgdkF $IfgdkFwkdP$$Ifl40N$$04 laf4yt\5J@K@B=BDByp $IfgdkF $IfgdkFgd,wkd$$Ifl40N$$04 laf4ytkFBBBBBBBBBBBCBDBEBJBRBSB]BaBmBwBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBjhUhhtjhtU h,hKK *h, *h/h,6DBEBBBBBBBBBBBBB|w!gdU xgd,wkd$$Ifl40N$$04 laf4ytkF BBBBgd,D00 PPP&P/ =!"#8$%h Dp$$If!vh#v#v:V l4 @@ss,554` sf4pssyt=!6{DyK  _Toc71204834{DyK  _Toc71204835{DyK  _Toc71204836{DyK  _Toc71204837{DyK  _Toc71204838{DyK  _Toc71204839{DyK  _Toc71204840{DyK  _Toc71204841{DyK  _Toc71204842{DyK  _Toc71204843{DyK  _Toc71204844{DyK  _Toc71204845{DyK  _Toc71204846{DyK  _Toc71204847{DyK  _Toc71204848{DyK  _Toc71204849{DyK  _Toc71204850{DyK  _Toc71204851{DyK  _Toc71204852{DyK  _Toc71204853{DyK  _Toc71204854{DyK  _Toc71204855{DyK  _Toc71204856{DyK  _Toc71204857{DyK  _Toc71204858{DyK  _Toc71204859{DyK  _Toc71204860{DyK  _Toc71204861{DyK  _Toc71204862{DyK  _Toc71204863{DyK  _Toc71204864{DyK  _Toc71204865{DyK  _Toc71204866{DyK  _Toc71204867{DyK  _Toc71204868{DyK  _Toc71204869{DyK  _Toc71204870{DyK  _Toc71204871{DyK  _Toc71204872{DyK  _Toc71204873{DyK  _Toc71204874{DyK  _Toc71204875{DyK  _Toc71204876{DyK  _Toc71204877{DyK  _Toc71204878{DyK  _Toc71204879{DyK  _Toc71204880{DyK  _Toc71204881{DyK  _Toc71204882{DyK  _Toc71204883{DyK  _Toc71204884{DyK  _Toc71204885{DyK  _Toc71204886{DyK  _Toc71204887{DyK  _Toc71204888{DyK  _Toc71204889{DyK  _Toc71204890{DyK  _Toc71204891{DyK  _Toc71204892{DyK  _Toc71204893{DyK  _Toc71204894{DyK  _Toc71204895{DyK  _Toc71204896{DyK  _Toc71204897{DyK  _Toc71204898{DyK  _Toc71204899{DyK  _Toc71204900{DyK  _Toc71204901{DyK  _Toc71204902{DyK  _Toc71204903{DyK  _Toc71204904{DyK  _Toc71204905{DyK  _Toc71204906{DyK  _Toc71204907{DyK  _Toc71204908$$If!vh#v#v:V l4 @@ss554f4pssyt=!6$$If!vh#v#v:V l4055/ / 4f4yt=!6$$If!vh#v#v:V l4055/ 4f4ytg$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4 t055/ Bf4ytK$$If!vh#v#v:V l4 t0$655/ Bf4ytkz DyK yK https://humanservices.arkansas.gov/wp-content/uploads/DMSUR.docyX;H,]ą'c!DyK yK https://humanservices.arkansas.gov/wp-content/uploads/ApplicationPacket.docyX;H,]ą'cDyK yK https://humanservices.arkansas.gov/wp-content/uploads/ProviderEnrol.docyX;H,]ą'cDyK yK https://humanservices.arkansas.gov/wp-content/uploads/DMSProgramCom.docyX;H,]ą'c$$If!vh#v#v:V l4055/ 4f4yt?V$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4DyK yK https://humanservices.arkansas.gov/wp-content/uploads/DDS-FS-0001-a.docyX;H,]ą'c$$If!vh#v#v:V l4 @@ss554f4pssyt=!6$$If!vh#v#v:V l4055/ / 4f4yt=!6$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l40$655/ 4f4yt8l$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$Ifedy!vh#v#v:V l4 t0$655/ Bf4ity$$If!vh#v#v:V l40$55/ 4f4ytfn$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l40$55/ 4f4ytfn$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l40$55/ 4f4yt`DyK yK https://humanservices.arkansas.gov/wp-content/uploads/DMS-615Checklist.docyX;H,]ą'cDyK yK https://humanservices.arkansas.gov/wp-content/uploads/ADACoordinator.docyX;H,]ą'c$$If!vh#v#v:V l4055/ 4f4DyK yK https://humanservices.arkansas.gov/wp-content/uploads/DMS-615Checklist.docyX;H,]ą'cDyK yK https://humanservices.arkansas.gov/wp-content/uploads/DMS-615Checklist.docyX;H,]ą'c$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ f4yta'DyK yK https://humanservices.arkansas.gov/wp-content/uploads/MAT_ICD-10_ProcCodes.docyX;H,]ą'c$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l40$655/ 4f4yt-DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_218.300_list_1.xlsyX;H,]ą'c-DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_218.300_list_2.xlsyX;H,]ą'c-DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_218.300_list_3.xlsyX;H,]ą'c$$If!vh#v#v:V l4055/ 4f4DyK yK https://humanservices.arkansas.gov/wp-content/uploads/AFMC.docyX;H,]ą'c$$If!vh#v#v:V l4K0$655/ / /  / 4f4yt DyK yK https://humanservices.arkansas.gov/wp-content/uploads/DMS-671.docyX;H,]ą'c$$If!vh#v#v:V l4K0$655/ / /  / 4f4$$If!vh#v#v:V l40$655/ / /  / 4f4$$If!vh#v#v:V l4K0$655/ / /  / 4f4$$If!vh#v#v:V l4055/ / /  / 4f4#DyK yK https://humanservices.arkansas.gov/wp-content/uploads/DHSAppealsHearings.docyX;H,]ą'c$$If!vh#v#v:V l4055/ 4f4DyK yK `https://medicaid.mmis.arkansas.gov/yX;H,]ą'c$$If!vh#v#v:V l4 @@ss554` sf4pssyt=!6$$If!vh#v#v:V l4 @@ss554` sf4pssyt=!6$$If!vh#v#v:V l4055/ 4f4DyK yK https://humanservices.arkansas.gov/wp-content/uploads/DMSFinancialActs.docyX;H,]ą'c$$If!vh#v#v:V l40$655/ / /  / f4ytUDyK yK `https://medicaid.mmis.arkansas.gov/yX;H,]ą'c$$If!vh#v#v:V l4 @@ss554f4pssyt=!6$$If!vh#v#v:V l4055/ / 4f4yt`$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4$$If!vh#vX#vk:V l4405X5k/ /  4af4$$If!vh#vX#vk:V l405X5k/ /  4af4$$If!vh#vX#vk:V l405X5k/ /  4af4$$If!vh#vX#vk:V l405X5k/ /  4af4$$If!vh#vX#vk:V l405X5k/ /  4af4$$If!vh#v#v:V l40$655/ / /  / 4f4ytB$$If!vh#v#v #v"#v#v:V lI 6` "6,55 5"55/ p2ytU)$$If!vh#v#v #v"#v#v:V l 6` "655 5"559/ p2ytU)$$If!vh#v#v #v"#v#v:V l 6` "655 5"559/ p2ytU)$$If!vh#v#v #v"#v#v:V l 6` "655 5"559/ p2ytU)$$If!vh#v#v #v"#v#v:V l 6` "655 5"559/ p2ytU)$$If!vh#v#v:V l40$655/ / /  / 4f4ytW$$If.!vh#v#vF#v*#v:V l4 t!,55F5*5/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If.!vh#v#vF#v*#v:V l( t!,55F5*59/ a.gytU)$$If!vh#v#v:V l40$655/ / /  / 4f4ytb$$If!vh#v#v:V l4055/ 4f4yt/@+DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V57.1.xlsyX;H,]ą'c$$If!vh#vX#vk:V l405X5k/ /  4af4yt/@+DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V57.2.xlsyX;H,]ą'c$$If!vh#vX#vk:V l405X5k/ /  4af4yt/@+DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V57.3.xlsyX;H,]ą'c$$If!vh#vX#vk:V l405X5k/ /  4af4yt/@+DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V72.5.xlsyX;H,]ą'c$$If!vh#vX#vk:V l405X5k/ /  4af4yt/@-DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V72.60.xlsyX;H,]ą'c$$If!vh#vX#vk:V l405X5k/ /  4af4yt/@$$If!vh#v#v:V l4055/ 4f4yt+DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.0.xlsyX;H,]ą'c$$If!vh#vX#vk:V l405X5k/ /  4af4yt/@+DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.3.xlsyX;H,]ą'c$$If!vh#vX#vk:V l405X5k/ /  4af4yt/@+DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.5.xlsyX;H,]ą'c$$If!vh#vX#vk:V l405X5k/ /  4af4yt/@+DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.7.xlsyX;H,]ą'c$$If!vh#vX#vk:V l405X5k/ /  4af4yt/@+DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.9.xlsyX;H,]ą'c$$If!vh#vX#vk:V l405X5k/ /  4af4yt/@-DyK yK https://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V72.85.xlsyX;H,]ą'c$$If!vh#vX#vk:V l405X5k/ /  4af4yt/@$$If!vh#v#v:V l4055/ 4f4$$If!vh#v#v:V l4055/ 4f4ytDyK yK https://humanservices.arkansas.gov/wp-content/uploads/SampleCMS-1450.docyX;H,]ą'c!DyK yK https://humanservices.arkansas.gov/wp-content/uploads/AmericanHospAssoc.docyX;H,]ą'c DyK yK https://humanservices.arkansas.gov/wp-content/uploads/Claims.docyX;H,]ą'c$$If!vh#v#v:V l40$55/ 4f4ytfn$$If!vh#v#v #v:V l440!,55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/  / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V lz0!55 5/ /  4aytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/  / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/  / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l4055 5/ /  4af4ytbA4$$If!vh#v#v #v:V l4055 5/ /  4af4ytbA4$$If!vh#v#v #v:V l4055 5/ /  4af4ytbA4$$If!vh#v#v #v:V l4055 5/ /  4af4ytbA4$$If!vh#v#v #v:V l4055 5/ /  4af4ytbA4$$If!vh#v#v #v:V l4055 5/ /  4af4ytbA4$$If!vh#v#v #v:V l4055 5/ /  4af4ytbA4$$If!vh#v#v #v:V l4055 5/ /  4af4ytbA4$$If!vh#v#v #v:V l4055 5/ /  4af4ytbA4$$If!vh#v#v #v:V l4055 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ / 4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v #v:V l40!55 5/ /  4af4ytbA4$$If!vh#v#v:V l4055/ 4f4yt\5$$If!vh#v#v:V l4055/ 4f4ytkF$$If!vh#v#v:V l4055/ 4f4ytkFIxpp002 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH @`@ 5NormalOJQJ_HmH sH tH \\ 5 Heading 1$$ LVP@&^`V 5OJQJLL 5 Heading 2$  @& 5OJQJP!P 5 Heading 3    @&]^ 5FF 5 Heading 4$$ @&a$5CJ FF 5 Heading 5$$1$@&a$5CJ 5 Heading 6]$$ xd$d%d&d'd@&NOPQ5CJDD 5 Heading 7$@&5CJOJQJPP n^ Heading 8 <@&6CJOJQJ]aJF F n^ Heading 9 <@& CJ^JaJDA`D 5Default Paragraph FontVi@V 5 Table Normal :V 44 la (k (5No List pop G2bchead2% @`<@&^``$5B*OJQJ_HmH phssH tH ,O, 5cTOCHeadZO!Z 5chead1 `<^``5;B*CJ\ph:O": @5ctexthx<^hCJNO2N H5 CLETTEREDdd^`CJPJ`OB` 5cletteredindent#d((1$^`CJNORN 5 cnumbered<<^`CJPJT/aT Z\cnumbered Char CJOJPJQJ_HmH sH tH BOrB 5cDate1$<<a$ 5B*ph^o^ 2bcDate2$<a$(5B*CJOJQJ_HmH phssH tH `@`2bpTOC 1" @`(^``5;B*mHnHphsud@d5pTOC 2+ -DM ^`CJPJmHnHuLU`L 50 Hyperlink!5>*B*CJH*OJQJS*phToT A5 cTableText <<CJOJQJ_HmH sH tH \V \ 5FollowedHyperlink!5>*B* CJH*OJQJS*ph.. 5TOC 3 ^FOF 5 ctableheading5B*\php@p 5Header,PM HEADER+ %&dP]^ 5CJhj @j5Footer+! %$dN]^5CJ\hmHnHu:O!": 5 ctablespace "H2H Dn^ Balloon Text#CJOJQJ^JaJ8"8 n^Caption $xx5\4R4 n^ Comment Text%@jQR@ n^Comment Subject&5\RYrR n^ Document Map'-D M OJQJ^J4+4 n^ Endnote Text(66 n^ Footnote Text):`: n^ HTML Address*6]: : n^Index 1+8^`8: : n^Index 2,8^`8: : n^Index 3-X8^X`8: : n^Index 4. 8^ `8:: n^Index 5/8^`8:: n^Index 608^`8:: n^Index 71x8^x`8:: n^Index 82@8^@`8:: n^Index 938^`8@!@ n^ Index Heading4 5\^Jl- Rl n^ Macro Text"5  ` @ OJQJ^J_HmH sH tH T,T n^Table of Authorities68^`8L#L n^Table of Figures7p^`pH.H n^ TOA Heading8x5CJ\^JaJ.. 5TOC 4 9X^X.. 5TOC 5 : ^ .. 5TOC 6 ;^.. 5TOC 7 <^.. 5TOC 8 =x^x.. 5TOC 9 >@^@FO!F 5Note? ^` 5PJ\HoH Gg ctext CharCJOJQJ_HmH sH tH R/R GgcTableText CharCJOJQJ_HmH sH tH @"@ U) ONBodyText Bxx@&CJB'`1B 7z*0Comment ReferenceCJaJN/AN #\Balloon Text CharCJOJQJ^JaJ$L$ F\DateE2/a2 E\ Date CharOJQJB/qB 2b chead2 Char5B*OJQJphsD/D 3CLETTERED CharCJOJPJQJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y :#l --EEEHk u7l^x0W! +2<BGbR_k7sI Uۚj~dd_  ]S!w%E,/4t:>BB !-:CGMRVYgz $u< x"1#M$(%%@.0k2^79>1FkHYKObR,STU\kcde0kZklnpr7sit6uO{ 9ܙYښ5`ߥeCǵnƺJN Bq@],*l>(vN b   L   N    ^    @ s    0X&eU#vR%s%%&S''%((*+\+w++,@,d,,,,,---->.}.../(/B/\/v////W00}11l222333344A5a55"66J77#88L9c:|;;;;<c<<<"=|===>:>Q>h>>>>$?`???? @J@DBBB     "#$%&'()*+,./0123456789;<=>?@ABDEFHIJKLNOPQSTUWXZ[\]^_`abcdefhijklmnopqrstuvwxy{|}~,[\{)+Jhj!KMl24SCEd"35T!UWv#%Dtv 3 5 T | ~  P R q   8 O Q p " $ C j l - / N l n ACb >@_!#BXZyLNmACb4OQp5mo.0Osu')Hrt  *bdz"" # #e###$S$^%%&000vHwzwnxxykÂi#fxw9ژɞ4|ڰ /B Qu -?Y]o' j|-fdv+V@kjy: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX̕XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX9@BH!@ @H 0(  0(  B S  ? _Hlk48203372 _Toc20534673 _Toc20534709 _Toc20537986 _Toc20534446 _Toc24252726 _Toc24443503 _Toc50444341 _Toc71204834 _Toc20537987 _Toc20534448 _Toc24252727 _Toc24443504 _Toc50444342 _Toc256683922 _Toc71204835 _Toc267398509 _Toc71204836 _Toc50444343 _Toc71204837 _Toc50444344 _Toc71204838 _Toc50444345 _Toc71204839 _Toc50444346 _Toc71204840 _Toc50444347 _Toc71204841 _Toc50444348 _Toc71204842 _Toc42566693 _Toc43793147 _Toc50444349 _Toc71204843 _Hlt51048332 _Toc50444350 _Toc71204844 _Toc50444352 _Toc50444351 _Toc71204845 _Toc71204846 _Toc50444353 _Toc71204847 _Toc50444354 _Toc71204848 _Toc50444355 _Toc71204849 _Toc43793154 _Toc50444356 _Toc71204850 _Toc50444357 _Toc71204851 _Toc50444358 _Toc71204852 _Toc50444359 _Toc71204853 _Toc43793158 _Toc50444360 _Toc71204854 _Toc50444361 _Toc475714594 _Toc71204855 _Toc50444362 _Toc71204856 _Toc50444363 _Toc71204857 _Toc50444364 _Toc71204858 _Toc50444365 _Toc71204859 _Toc50444366 _Toc71204860 _Toc50444368 _Toc50444367 _Toc71204861 _Toc71204862 _Toc50444369 _Toc71204863 _Toc50444370 _Toc71204864 _Toc50444371 _Toc71204865 _Toc50444372 _Toc71204866 _Toc40064400 _Toc42566728 _Toc50444374 _Toc71204867 _Hlt51047752 _Hlt51047746 _Hlt51048343 _Hlt51047776 _Toc71204868 _Toc71204869 _Toc71204870 _Toc43793175 _Toc50444377 _Toc71204871 _Toc43793176 _Toc50444378 _Toc71204872 _Toc43793177 _Toc50444379 _Toc71204873 _Toc43793178 _Toc50444380 _Toc71204874 _Toc43793179 _Toc50444381 _Toc71204875 _Toc43793180 _Toc50444382 _Toc71204876 _Toc381105277 _Toc71204877 _Hlt422468946 _Hlt422468947 _Toc71204878 _Toc71204879 _Toc71204880 _Toc71204881 _Toc71204882 _Toc71204883 _Toc40064412 _Toc42566741 _Toc43793184 _Toc50444386 _Toc71204884 _Toc50444387 _Toc71204885 _Toc50444388 _Toc71204886 _Toc43793187 _Toc50444389 _Toc71204887 _Toc50444390 _Toc71204888 _Toc50444392 _Toc50444391 _Toc71204889 _Toc71204890 _Toc50444393 _Toc71204891 _Hlt51048370 _Toc71204892 _Toc50444394 _Toc71204893 _Toc50444395 _Toc71204894 _Toc50444396 _Toc71204895 _Toc50444397 _Toc71204896 _Toc50444398 _Toc71204897 _Toc71204898 _Toc71204899 _Toc71204900 _Toc381105300 _Toc71204901 _Toc50444400 _Toc381105301 _Toc71204902 _Toc50444401 _Toc71204903 _Toc50444402 _Toc71204904 _Hlt51046725 _Hlt51046727 _Hlt474836877 _Hlt474836878 _Toc71204905 _Toc50444404 _Toc71204906 _Toc71204907 _Toc71204908RR##zz&&B(B(&*&*&*&*0111116??@@BB}G}G}G)J)JJJiLiLMMMSSSN[N[u\u\]]cc2c2cdddBgiijjjj?@ABCDEFGJHIKLMNOPQRSYZ[TU@V@W@X@\]^_`abcdefghijklmnopqrs@t@uvwxyz{|}~@@@@@;;;Zo''EE  6&6&((.*a*a*a*0111166@@a@a@OCOCGGGXJXJ"K"KLLMMMTTTj[j[\\]]/c/cPcPcddigigiijj-k-k_l_l,mbwtwx yzzz{ 1ґґґOOOВВВ+++WWpp՝MӨBddջջyz'  mmRH88B8<::9... . ..... . . .!.".#. $. %. &. '. (. ). *. +. ,. -. .. /. 0. 1. 2. 3. 4. 5. 6. 7. 8. 9. :. ;. <. =. >. ?. @. A. B. C. D. E. F. G. H. I. J.K.L.M.(F< < (b*b+b+//b@PCGYJ#KLM\]Qcjg.k`lӑP,NԨCeGz-Evƻ R%%%%:      !"#$%&'()*+,-./0123456780LD D (j*j+j+//j@XCGaJ+KLM\]Ycrg6khlۑX4TڨIƭmŲV<Tջ^"%%%%:  !"#$%&'()*+,-./01234567894*urn:schemas-microsoft-com:office:smarttagsplace88*urn:schemas-microsoft-com:office:smarttagsCity99*urn:schemas-microsoft-com:office:smarttagsState=*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType87*urn:schemas-microsoft-com:office:smarttagsdate8*urn:schemas-microsoft-com:office:smarttagstimeB5*urn:schemas-microsoft-com:office:smarttagscountry-region Q1101322001200320042005200747DayMonthYear987   7 54947   7   94947   7   7   7   7   7   7   7   7   7   7   7   7   7   7   7   7  7  7  7  7  7   7   7   7 7 7 7 7 7 7 7 7 7 7 7 7 7   7   4hpظY_[aagqwV\flw}OU!'_e,,{..::::::::::: W&^&.. 0000338 8V8_8N9U9|99::;;@@ AA\AaAAADDaDfDDDHHJJfWoWYYZZyaabbee3h9hhillnn`qhqq}y}~~ 07?Jmu!^lɹѹ|!-C.J.3%399:::::::::::333333333333333333333333333333333333333333333333333333,{"" #e##$_%%00vHwoxxlÂi$fw:ʞ ,-e A\]3iNijrHcdb,?@Sij:::::::::::::::::,{"" #e##$_%%00vHwoxxlÂi$fw:ʞ ,-e A\]3iNijrHcdb,?@Sij:::::::::::::: |sD}FF~vļ('f3(]RH "TFN-^:h^`.^`.88^8`.^`. ^`OJQJo( ^`OJQJo( 88^8`OJQJo( ^`OJQJo(hh^h`. hh^h`OJQJo(V %V ^V `%B*CJOJQJo(ph.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L. -^:~}| Hx        y e`|Ggg*J2T(-tp?N'mcHU)p 7$.,3 $.RC ]F #A&?&Q`&^]*7z*b/$3^3bA4\5=!6!m:|<-=/@Ihttps://humanservices.arkansas.gov/wp-content/uploads/SampleCMS-1450.docER;Rhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V72.85.xlsJ8Qhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.9.xlsJ5Qhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.7.xlsJ2Qhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.5.xlsJ/Qhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.3.xlsJ,Qhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.120_V70.0.xlsC\)Rhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V72.60.xlsI&Qhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V72.5.xlsK#Qhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V57.3.xlsK Qhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V57.2.xlsKQhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_252.110_V57.1.xls70$https://medicaid.mmis.arkansas.gov/miKhttps://humanservices.arkansas.gov/wp-content/uploads/DMSFinancialActs.doc70$https://medicaid.mmis.arkansas.gov/ Mhttps://humanservices.arkansas.gov/wp-content/uploads/DHSAppealsHearings.docPFBhttps://humanservices.arkansas.gov/wp-content/uploads/DMS-671.docir ?https://humanservices.arkansas.gov/wp-content/uploads/AFMC.docAfRhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_218.300_list_3.xls@fRhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_218.300_list_2.xlsCfRhttps://humanservices.arkansas.gov/wp-content/uploads/RURLHLTH_218.300_list_1.xls\Ohttps://humanservices.arkansas.gov/wp-content/uploads/MAT_ICD-10_ProcCodes.docevKhttps://humanservices.arkansas.gov/wp-content/uploads/DMS-615Checklist.docevKhttps://humanservices.arkansas.gov/wp-content/uploads/DMS-615Checklist.docIhttps://humanservices.arkansas.gov/wp-content/uploads/ADACoordinator.docevKhttps://humanservices.arkansas.gov/wp-content/uploads/DMS-615Checklist.doc|&Hhttps://humanservices.arkansas.gov/wp-content/uploads/DDS-FS-0001-a.doc-3Hhttps://humanservices.arkansas.gov/wp-content/uploads/DMSProgramCom.doc("Hhttps://humanservices.arkansas.gov/wp-content/uploads/ProviderEnrol.doc #Lhttps://humanservices.arkansas.gov/wp-content/uploads/ApplicationPacket.doc%)@https://humanservices.arkansas.gov/wp-content/uploads/DMSUR.doc1 _Toc712049081 _Toc712049071 _Toc712049061 _Toc712049051 _Toc712049041 _Toc712049031 _Toc712049021 _Toc712049011 _Toc712049008 _Toc712048998 _Toc712048988 _Toc712048978 _Toc712048968 _Toc712048958 _Toc712048948 _Toc712048938 _Toc712048928 _Toc712048918 _Toc712048909 _Toc712048899 _Toc712048889 _Toc712048879 _Toc712048869 _Toc712048859 _Toc712048849 _Toc712048839 _Toc712048829 _Toc712048819 _Toc712048806 _Toc712048796 _Toc712048786 _Toc712048776 _Toc712048766} _Toc712048756z _Toc712048746w _Toc712048736t _Toc712048726q _Toc712048716n _Toc712048707k _Toc712048697h _Toc712048687e _Toc712048677b _Toc712048667_ _Toc712048657\ _Toc712048647Y _Toc712048637V _Toc712048627S _Toc712048617P _Toc712048604M _Toc712048594J _Toc712048584G _Toc712048574D _Toc712048564A _Toc712048554> _Toc712048544; _Toc7120485348 _Toc7120485245 _Toc7120485142 _Toc712048505/ _Toc712048495, _Toc712048485) _Toc712048475& _Toc712048465# _Toc712048455  _Toc712048445 _Toc712048435 _Toc712048425 _Toc712048415 _Toc712048402 _Toc712048392 _Toc712048382  _Toc712048372 _Toc712048362 _Toc712048352 _Toc71204834  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`acdefghiklmnopqrstuvwxyz{|}~Root Entry FɗB Data $1Table#|WordDocumentFlSummaryInformation(bDocumentSummaryInformation8j3MsoDataStore u—B0ǗBVZBIU203D==2u—BėBItem  PropertiesOA1CUCZUWJA==2 u—BėBItem  PropertiesULYJES2P2QDA==2u—B0ǗBItem .Properties  !"#%DocumentLibraryFormDocumentLibraryFormDocumentLibraryForm This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision. tomXml">  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89qCompObj$r