016.06.06 Ark. Code R. 080
TOC not required
Dental services for ARKids First-B participants are limited to one periodic dental exam, bite-wings, and prophylaxis/fluoride treatments every six (6) months plus one (1) day. See section 262.100 to view the procedure code for periodic dental screening exams. Scalings are limited to once per State Fiscal Year (SFY).
The procedure codes listed in the table below may be billed for the prophylaxis/fluoride.
Procedure Code | Description |
D1110 | Prophylaxis - adult (ages 10-20) |
D1120 | Prophylaxis - child (ages 0-9) |
D1201 | Topical application of fluoride (including prophylaxis) - child (ages 0-9) |
D1205 | Topical application of fluoride (including prophylaxis) - adult (ages 10-18) |
Refer to Section II of the Dental Provider Manual for a complete listing of covered dental services. Orthodontia Services are not covered for ARKids First-B participants.
Procedure codes for treatment services that are not shown as payable may be requested on treatment plans subject to review and approval by the Division of Medical Services dental consultants if such treatment is deemed medically necessary.
Procedure code D0120 must be billed for an initial/periodic preventive dental screening.
ARKids B participants may receive interperiodic preventive dental screening. There is no limit on this service. However, prior authorization must be obtained in order to receive reimbursement. See Section 240.200 for prior authorization information.
Procedure code D0140 must be billed for an interperiodic preventive dental screen. This service requires prior authorization.
Prior authorization for procedure code D0140, Interperiodic Dental Screening Exam, must be requested on the ADA claim form or online with a brief narrative through the Prior Authorization Manipulation (PAM) software. View or print the Department of Health and Human Services Medicaid Dental Unit address.
Refer to Section 222.310 of this manual for coverage and billing information.
ARKids First-B
The following medical supplies procedure codes may be billed by Medicaid-enrolled Home Health and Prosthetics providers for ARKids First-B participants. Type of service (TOS) codes are used only when billing on paper.
A4206 | A4221 | A4222 | A4253 U1 | A4256 |
A4259 U2 | A4265 | A4310 | A4311 | A4312 |
A4313 | A4314 | A4315 | A4316 | A4320 |
A4322 | A4326 | A4327 | A4328 | A4330 |
A4338 | A4340 | A4344 | A4346 | A4348 |
A4351 | A4352 | A4354 | A4355 | A4356 |
A4357 | A4358 | A4359 | A4361 | A4362 |
A4364 | A4367 | A4369 | A4371 | A4397 |
A4398 | A4399 | A4400 | A4402 | A4404 |
A4405 | A4406 | A4450 | A4452 | A4455 |
A4558 | A4561 | A4562 | A4623 | A4624 |
A4625 | A4626 | A4628 | A4629 | A4772 |
A4927 | A5051 | A5052 | A5053 | A5054 |
A5055 | A5061 | A5062 | A5063 | A5071 |
A5072 | A5073 | A5081 | A5082 | A5093 |
A5102 | A5105 | A5112 | A5113 | A5114 |
A5120 | A5121 | A5122 | A5126 | A5131 |
A6154 | A6234 | A6241 | A6242 | A6248 |
A7520 | B4086 | E0776 |
Procedure Code | Required Modifier(s) | TOS Code | Description |
A6257 | - | Transparent film, each (16 square inches or less) | |
A6258 | - | Transparent film, each (more than 16, but less than 48 square inches) | |
A6259 | - | Transparent film, each (more than 48 square inches) | |
A6216 A6219 A6228 | - | Gauze pads medicated or non-medicated, each (16 square inches or less) | |
A6217 A6220 A6229 | - | Gauze pads medicated or non-medicated, each (more than 16, but less than 48 square inches) | |
A6403 | |||
A6204 A6218 A6221 A6230 | - | Gauze pads medicated or non-medicated, each (more than 48 square inches) | |
A6441 A6446 | - | Gauze, non-elastic, per roll (1 linear yard) | |
A6242 A6245 | - | Hydrogel dressing, each (16 square inches or less) | |
A6243 A6246 | - | Hydrogel dressing, each (more than 16, but less than 48 square inches) | |
A6244 A6247 | - | Hydrogel dressing, each (more than 48 square inches) | |
A6248 | - | Hydrogel dressing, each (1 ounce) | |
A6234 A6237 | - | Hydrocolloid dressing, each (16 square inches or less) | |
A6235 A6238 | - | Hydrocolloid dressing, each (more than 16, but less than 48 square inches) | |
A6238 | U1 | Hydrocolloid dressing, each (more than 48 square inches) | |
A6196 | - | Alginate dressing, each (16 square inches or less) | |
A6197 | - | Alginate dressing, each (more than 16, but less than 48 square inches) | |
A6198 | - | Alginate dressing, each (more than 48 square inches) | |
A6197 | - | Alginate dressing, each (1 linear yard) | |
A6209 A6212 | - | Foam dressing, each (16 square inches or less) | |
A6210 A6213 | - | Foam dressing, each (more than 16, but less than 48 square inches) | |
A6211 | - | Foam dressing, each (more than 48 square inches) | |
A6200 A6203 | - | Composite dressing, each (16 square inches or less) | |
A6201 A6204 | - | Composite dressing, each (more than 16, but less than 48 square inches) | |
A6202 A6205 | - | Composite dressing, each (more than 48 square inches) | |
A4253 | - | Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips | |
A4353 | - | Urinary intermittent catheter with insertion supplies | |
A4394 | - | Ostomy deodorant, all types, per ounce | |
A4365 | - | Adhesive remover wipes, any type, per 50 | |
A4368 | - | Ostomy filters, any type, each | |
A6449 A6452 | - | Gauze elastic, all types, per roll (linear yard) | |
A4483 | - | Moisture exchange/agreer, disposable, for use with invasive mech | |
B4100 | - | H | Food thickener, administered orally, per oz. |
A6549* | - | Stocking (Jobst) |
*NOTE: A4221, A4222 and A6549 must be prior authorized. Form AFMC-103 must be used for the request for prior authorization. View or print form AFMC-103 and instructions for completion.
The costs of B4100 and A6549 are not subject to the $125 medical supplies monthly benefit limit.
The following procedure code must be utilized when billing for Pedia-Pop. Reimbursement for this product is provider's cost plus ten percent. Pedia-Pop is only for oral consumption, and only in frozen form.
Z2487 Pedia-Pop 1 unit = 1 box Maximum = 2 units per date of service
NOTE: Pedia-Pop must be billed on paper.
016.06.06 Ark. Code R. 080