016.06.06 Ark. Code R. 033
Provider Manual | Transmittal Number | ||
Alternatives for Adults with Physical Disabilities Waiver.................................................. | ........36 | ||
Ambulatory Surgical Center............................................................................................. | ........68 | ||
ARKids First-B................................................................................................................. | ........34 | ||
Certified Nurse-Midwife.................................................................................................... | ........72 | ||
Child Health Management Services................................................................................. | ........70 | ||
Child Health Services/Early and Periodic Screening, Diagnosis and Treatment.............. | ........76 | ||
Children's Services Targeted Case Management............................................................ | ........22 | ||
Chiropractic...................................................................................................................... | ........65 | ||
DDS Alternative Community Services Waiver.................................................................. | ........63 | ||
Dental............................................................................................................................... | ........88 | ||
Developmental Day Treatment Clinic Services................................................................ | ........72 | ||
Developmental Rehabilitation Services............................................................................ | ........22 | ||
Division of Youth Services and Division of Children and Family Services Targeted Case Management............................................................................... | ........14 | ||
Domiciliary Care............................................................................................................... | ........50 | ||
ElderChoices Home and Community-Based 2176 Waiver............................................... | ........64 | ||
Federally Qualified Health Center.................................................................................... | ........59 | ||
Hearing Services.............................................................................................................. | ........61 | ||
Home Health.................................................................................................................... | ........79 | ||
Hospice............................................................................................................................ | ........51 | ||
Hospital/End-Staqe Renal Disease.................................................................................. | ........94 | ||
Hyperalimentation............................................................................................................ | ........77 | ||
Inpatient Psychiatric Services for Under Age 21.............................................................. | ........70 | ||
Licensed Mental Health Practitioners............................................................................... | ........54 | ||
Living Choices Assisted Living......................................................................................... | ........20 | ||
Medicare/Medicaid Crossover Only................................................................................. | ........47 | ||
Nurse Practitioner............................................................................................................ | ........68 | ||
Occupational, Physical, Speech Therapy Services.......................................................... | ........61 | ||
Personal Care.................................................................................................................. | ........74 | ||
Pharmacy......................................................................................................................... | ........87 | ||
Provider Manual | Transmittal Number | ||
Physician/Independent Lab/CRNA/Radiation Therapy Center..................... | ..........................115 | ||
Podiatrist...................................................................................................... | .............................67 | ||
Portable X-Ray Services.............................................................................. | .............................56 | ||
Private Duty Nursinq Services..................................................................... | .............................67 | ||
Prosthetics................................................................................................... | .............................79 | ||
Rehabilitative Hospital.................................................................................. | .............................64 | ||
Rehabilitative Services for Persons with Mental Illness............................... | ............................69 | ||
Rehabilitative Services for Persons with Physical Disabilities...................... | ............................42 | ||
Rehabilitative Services for Youth and Children............................................ | ............................24 | ||
Rural Health Clinic Services......................................................................... | .............................59 | ||
School-Based Mental Health Services......................................................... | ............................27 | ||
Tarqeted Case Manaqement....................................................................... | .............................60 | ||
Transportation.............................................................................................. | .............................79 | ||
Ventilator Equipment.................................................................................... | .............................61 | ||
Visual Care.................................................................................................. | .............................75 | ||
REMOVE | INSERT | ||
Section | Date | Section | Date |
DMS-640 | 8/05 | DMS-640 | 7/06 |
Explanation of Updates
Form DMS-640 has been revised to reflect the expenditure data for state fiscal year (SFY) 2005.
Paper versions of this update transmittal have updated pages attached to file in your provider manual. See Section I for instructions on updating the paper version of the manual. For electronic versions, these changes have already been incorporated.
If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at (501) 682-6789 (TDD only).
If you have questions regarding this transmittal, please contact the EDS Provider Assistance Center at 1-800-457 -4454 (Toil-Free) within Arkansas or locally and Out-of-State at (501) 376-2211.
Arkansas Medicaid provider manuals (including update transmittals), official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.
Thank you for your participation in the Arkansas Medicaid Program.
I nstructions for Completion
Form DMS-640 - Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21 PRESCRIPTION /REFERRAL
* If DMS-640 is used to make an initial referral for evaluation, check the referral box only. After receiving the evaluation results and determining that therapy is necessary, you must use a separate DMS-640 form to prescribe the therapy. Check the treatment box for prescription and complete the form following the instructions below. If the referral and prescription are for previously prescribed services, you may check both boxes.
* Patient Name - Enter the patient's full name.
* Medicaid ID # - Enter the patient's Medicaid ID number. Physician/Physician's office staff must complete the following:
* Date Child Was Last Seen In Office - Enter the date of the last time you saw this child. (This could be either for a complete physical examination, a routine check-up or an office visit for other reasons requiring your personal attention.)
* Primary Diagnosis - Enter the primary medical diagnosis description or ICD-9 diagnosis code.
* Diagnosis as Related to Prescribed Treatment - Enter the diagnosis that indicates or establishes medical necessity for prescribed therapy.
* Prescription block - If the form is used for a prescription, enter the prescribed number of minutes per week and the prescribed duration (in months) of therapy.
* If therapy is not medically necessary at this time, check the box.
* Other Information - Any other information pertinent to the child's medical condition, plan of treatment, etc., may be entered.
* Primary Care Physician (PCP) Name and Medicaid Provider Number - Print the name of the prescribing PCP and his or her Medicaid provider number.
* Attending Physician Name and Medicaid Provider Number - If the Medicaid-eligible child is exempt from PCP requirements, print the name of the prescribing attending physician and his or her Medicaid provider number.
* Physician Signature and Date - The prescribing physician must sign and date the prescription for therapy in his or her original signature.
*These therapy amounts include therapy provided in a Developmental Day Treatment Center (DDTCS)
The original of the completed form DMS-640 must be maintained in the child's medical records by the prescribing physician. A copy of the completed form DMS-640 must be retained by the therapy provider.
016.06.06 Ark. Code R. 033