016-06-05 Ark. Code R. § 33
Claim Forms
Red-ink Claim Forms
The following is a listing of the red-ink claim forms required by Arkansas Medicaid. The forms below cannot be printed from this manual for use. Information on where to get the forms and links to samples of the forms are available below. To view a sample of the form click on the form name.
Claim type | Where to get them |
Professional - CMS-1500 | Business Form Supplier |
Institutional - CMS-1450 | Business Form Supplier |
EPSDT - DMS-694 | EDS - 1-800-457 -4454 |
Visual Care - DMS-26-V | EDS - 1-800-457 -4454 |
Outpatient Crossover - EDS-MC-003 | EDS - 1-800-457 -4454 |
Professional Crossover - EDS-MC-004 | EDS - 1-800-457 -4454 |
Inpatient Crossover - EDS-MC-001 | EDS - 1-800-457 -4454 |
Long Term Care Crossover - EDS-MC-002 | EDS - 1-800-457 -4454 |
Claim Forms
The following is a listing of the non-red-ink claim forms required by Arkansas Medicaid. Information on where to get a supply of the forms and links to samples of the forms are available below. To view a sample of the form click on the form name.
Claim type | Where to get them |
Alternatives Attendant Care Provider Claim Form -AAS-9559 | Client Employer |
Dental - ADA-J510 | Business Form Supplier |
Hospice/INH Claim Form - DHS-754 | EDS - 1-800-457 -4454 |
Arkansas Medicaid Forms
The forms below can be printed from this manual for use.
Form Name | Form Number |
Acknowledgement of Hysterectomy Information | DMS-2606 |
Address Change Form | None |
Adjustment Request Form - Medicaid XIX | EDS-AR-004 |
AFMC CHMS Request for Prior Authorization | CHMS-PA |
AFMC Personal Care Assessment and Service Plan for Medicaid Recipients Under Age 21 | AFMC-201 |
AFMC Request For Bilaminate Skin Substitutes | AFMC-RBSS |
AFMC Request for Occupational, Physical, and Speech Therapy Prior Authorization for Medicaid Recipients Under Age 21 | AFMC-401 |
Agreement Between Parent(s) and Respite Caregiver | RC-A |
Amplification/Assistive Technology Recommendation Form | DMS-686 |
Approval/Denial Codes for Inpatient Psychiatric Services | DMS-2687 |
Arkansas Early Intervention Infant & Toddler Program Intake/Referral/Application for Services | DDS/FS#0001.a |
Arkansas Medicaid Provider Application and Contract | DMS-652 |
ARKids First Mental Health Services Provider Qualification Form | DMS-612 |
Assisted Living Waiver Plan of Care | AAS-9565 |
Authorization for Payment for Services Provided | MAP-8 |
Certification of Need - Medicaid Inpatient Psychiatric Services for Under Age 21 | DMS-2633 |
Certification of Schools to Provide Comprehensive EPSDT Services | CSPC-EPSDT |
Certification Statement for Abortion | DMS-2698 |
CHMS Benefit Extension for Diagnosis/Evaluation or Specified Treatment Procedures | CHMS-DET |
CHMS Benefit Extension for Diagnosis/Evaluations or Treatment | DMS-625 |
CHMS Benefit Extension for Occupational, Physical and Speech Therapy Services | DMS-629 |
Claim Correction Request | DMS-2647 |
Children's Services Respite Care Waiver Level of Functioning Survey for the Mentally Retarded/Developmentally Disabled Summary Sheet | DMS-666 |
Children's Services Respite Care Waiver Level of Functioning Survey for the Physically Disabled Summary Sheet | DMS-667 |
Consent for Release of Information | DMS-619 |
DDTCS Transportation Log | DMS-638 |
DDTCS Transportation Survey | DMS-632 |
Dental Treatment Additional Information | DMS-32-A |
Disproportionate Share Questionnaire | DMS-628 |
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Prescription/Referral For Medically Necessary Services/Items Not Specifically Included in the Medicaid State Plan | DMS-693 |
Early Childhood Special Education Referral Form | ECSE-R |
EPSDT Provider Agreement | EPSDT-PA |
Evaluation Form Lower-Limb | DMS-646 |
Explanation of Check Refund | EDS-CR-002 |
Family Friends Children's Services Respite Care Waiver Freedom of Choice and Fair Hearing | DMS-669 |
Family Friends Children's Services Respite Care Waiver Plan of Care | DMS-661 |
Family Friends Respite Care Application Form For Families | DMS-851 |
Gait Analysis Full Body | DMS-647 |
Home Health Certification and Plan of Care | CMS-485 |
Hospital/Physician/Certified Nurse Midwife Referral for Newborn Infant Medicaid Coverage | DCO-645 |
Inpatient Psychiatric Medicaid Agency Review Team Transmittal Sheet | DMS-2685 |
Lower-Limb Prosthetic Prescription | DMS-651 |
Media Selection/E-Mail Address Change Form | None |
Medicaid Claim Inquiry Form | EDS-CI-003 |
Medicaid Form Request | EDS-MFR-001 |
Medical Assistance Dental Disposition | DMS-2635 |
Medical Equipment Request for Prior Authorization & Prescription | DMS-679 |
Medical Transportation and Personal Assistant Verification | DMS-616 |
Mental Health Services Provider Qualification Form for LCSW, LMFT and LPC | DMS-633 |
Notice Of Noncompliance | DMS-635 |
Occupational, Physical and Speech Therapy for Medicaid Eligible Recipients Under Age 21 Prescription/Referral | DMS-640 |
Personal Care Assessment and Service Plan | DMS-618 |
Primary Care Physician Managed Care Program Referral Form | DMS-2610 |
Primary Care Physician Selection and Change Form | DMS-2609 |
Prosthetic-Orthotic Lower-Limb Amputee Evaluation | DMS-650 |
Prosthetic-Orthotic Upper-Limb Amputee Evaluation | DMS-648 |
Provider Communication Form | AAS-9502 |
Referral for Certification of Need Medicaid Inpatient Psychiatric Services for Under Age 21 | DMS-2634 |
Referral for Medical Assistance | DMS-630 |
Request for Approval | DMS-617 |
Request for Authorization of Child Health Management Services | DMS-624 |
Request for Extension of Benefits | DMS-699 |
Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services | DMS-671 |
Request for Extension of Benefits for Medical Supplies for Medicaid Recipients Under Age 21 | DMS-602 |
Request For Orthodontic Treatment | DMS-32-0 |
Request for Prior Authorization and Prescription for Hyperalimentation | DMS-2615 |
Request for Private Duty Nursing Services Prior Authorization and Prescription - Initial Request or Recertification | DMS-2692 |
Request for Speech Therapy Prior Authorization for ARKids First-B Participants | DMS-623 |
Request for Targeted Case Management Prior Authorization for Recipients Under Age 21 | DMS-601 |
Service Agreement and Certification/Delegation of Children's Services Respite Caregiver | DMS-852 |
Sterilization Consent Form | DMS-615 |
Sterilization Consent Form - Information for Men | PUB-020 |
Sterilization Consent Form - Information for Women | PUB-019 |
Upper-Limb Prosthetic Prescription | DMS-649 |
Verification of Medical Services | DMS-2618 |
Arkansas Medicaid Contacts and Links
Click on the name to view the needed information.
American Hospital Association
Americans with Disabilities Act Coordinator
APS Healthcare Midwest (APS)
Arkansas Benefit Limits Review Committee Utilization Review Section
Arkansas Department of Education Special Education
Arkansas Department of Health
Arkansas Department of Health Division of Health Facility Services
Arkansas Department of Human Services Accounts Receivable
Arkansas Department of Human Services Children's Medical Services Family Friends CMS Respite Care
Arkansas Department of Human Services Division of Medical Services
Arkansas Department of Human Services Division of Medical Services, Provider Reimbursement Unit
Arkansas Department of Human Services, Division of Child Care and Early Childhood Education, Child Care Licensing Unit
Arkansas Department of Human Services, Division of Children and Family Services, Contracts Management Unit
Arkansas Division of Medical Services Benefit Extension Requests Section
Arkansas Division of Medical Services Director
Arkansas Division of Medical Services Financial Activities Unit
Arkansas Division of Medical Services Hearing Aid Consultant
Arkansas Division of Medical Services Medical Assistance Unit
Arkansas Division of Medical Services Program Communications Unit
Arkansas Division of Medical Services Third-Party Liability Unit
Arkansas Division of Medical Services UR/Home Health Extensions
Arkansas Division of Medical Services Utilization Review Section
Arkansas Division of Medical Services Visual Care Coordinator
Arkansas Foundation For Medical Care
Arkansas Hospital Association Contact Information
Arkansas Medicaid Provider Enrollment Unit
ARKids First-B ID Card Example
ARKids First-B Telephone Number
Central Child Health Services Office
Children's Services
Classical Optical
ConnectCare Helpline
County Codes
CPT Ordering Information
Department of Human Services - Appeals and Hearings Section
Division of Aging and Adult Services
Division of County Operations - Customer Assistance Section
Division of Medical Services Dental Care Unit
Division of Medical Services Pharmacy Unit-Utilization Review Section
EDS Claims Department
EDS EDI Support Center (formerly AEVCS Help Desk)
EDS Inquiry Unit
EDS Manual Order Address
EDS Pharmacy Help Desk
EDS Provider Assistance Center (PAC)
EDS Supplied Forms
Example of Recipient Notification of Denied ARKids First-B Claim
Example of Recipient Notification of Denied Medicaid Claim
First Connections Infant & Toddler Program Developmental Disabilities Services
First Health
Flow Chart of Intake and Prior Authorization Process For Intervention/Treatment
Health and Nursing Services Specialist
Health Care Declarations
ICD-9-CM Ordering Information
Immunizations Data Entry Office
Medicaid ID Card Example
Medicaid Reimbursement Unit Communications Hotline
Medicaid Tooth Numbering System
National Supplier Clearinghouse
Primary Care Physician (PCP) Enrollment Voice Response System
Provider Qualifications Division of Mental Health Services
Standard Register
Table of Desirable Weights
U.S. Government Printing Office
Vendor Performance Report
016.06.05 Ark. Code R. § 033