Instructions for Completion of the Professional Services Medicare – Medicaid Crossover Invoice – HP-MC-004

The Arkansas Medicaid fiscal agent offers providers several options for electronic billing. Therefore, claims submitted on paper are paid once a month. The only claims exempt from this process are those which require attachments or manual pricing.

To bill for Medicare – Medicaid crossover professional services, use the claim form HP-MC-004. The numbered items correspond to fields on the claim form. Each service should be billed separately, providing the appropriate information for each.

Read and carefully adhere to the following instructions. Accuracy, completeness and clarity are important. Claims cannot be processed if applicable information is not supplied or is illegible. Paper claims should be typed whenever possible.

Completed claim forms should be forwarded to the Claims Department. View or print the ClaimsDepartment contact information.

NOTE:A provider rendering services without verifying eligibility for each date of service does so at the risk of not being reimbursed for the services.

Field Name and Number / Instructions for Completion
Header 1
1.Medicaid Provider ID / Enter your 9-digit Arkansas Medicaid billing provider ID number.
2.Beneficiary
A.ID / Enter the patient’s10-digit Medicaid ID number.
B.First Name / Enter the first initial of the patient’s first name.
C.Last Name / Enter the first two letters of the patient’s last name.
3.Patient Account # / Enter your office identifier.
4.Medicare ICN / Enter the Internal Control Number (ICN) from the MedicareExplanation of Benefits (EOB).
5.From DOS / Enter the first date of service for the claim.
6.To DOS / Enter the last date of service for the claim.
7.Procedure / Enter the five-digit procedure code for the first procedure billed.
8.Primary Modifier / Enter the first modifier that applies to the procedure.
9.Secondary Modifier / Enter the second modifier that applies to the procedure.
10.Units / Enter the number of units billed for this procedure.
Header 2
11.Other Insurance Amount / Enter the amount paid by a third-party insurance company; if none, enter 0 (zero). This would be a company like Blue Cross, Health Advantage, etc.
12.Medicare Coinsurance / Enter the coinsurance amount for the entire claim from the Medicare EOB.
13.Medicare Deductible / Enter the deductible amount for the entire claim from the Medicare EOB.
14.Medicare Non-Covered / Enter the Medicare Non-Covered amount for the entire claim from the Medicare EOB information.
15.Medicare Paid / Enter the Medicare Paid amount for the entire claim from the Medicare EOB.
16.Medicare Paid Date / Enter the date that is printed on the Medicare EOB.
17. Total Medicare Billed / Enter the total billed amount for the entire claim from the Medicare EOB.
18. Total Medicare Allowed / Enter the total allowed amount for the entire claim from the Medicare EOB.
19.Net Billed / Enter the total billed amount minus any other private insurance payment. This excludes any Medicare or replacement policy insurance.