016.06.07 Ark. Code R. 022
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 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 |
Inpatient Crossover ? EDS-MC-001 | EDS - 1-800-457 -4454 |
Long Term Care Crossover ? EDS-MC-002 | 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 |
** A printable PROVIDER INTEROFFICE DOCUMENTATION ONLY version of this form is available below under Arkansas Medicaid Forms.
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 the form name.
Claim Type | Where To Get Them |
Alternatives Attendant Care Provider Claim Form -AAS-9559 | Client Employer |
Dental ? ADA-J400 | 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.
In order by form name:
Form Name | Form Number |
Acknowledgement of Hysterectomy Information | DMS-2606 |
Address Change Form | DMS-673 |
Adjustment Request Form - Medicaid XIX | EDS-AR-004 |
AFMC Personal Care Assessment and Service Plan for Medicaid Beneficiaries Under Age 21 | AFMC-201 |
AFMC Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components | AFMC-103 |
AFMC Request For Bilaminate Skin Substitutes | AFMC-RBSS |
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 |
ARKids First Mental Health Services Provider Qualification Form | DMS-612 |
Assisted Living Waiver Plan of Care | AAS-9565 |
Authorization for Automatic Deposit | autodeposit |
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 Procedures | AFMC-102 |
CHMS Request for Prior Authorization | AFMC-101 |
Claim Correction Request | DMS-2647 |
Consent for Release of Information | DMS-619 |
Contract to Participate in the Arkansas Medical Assistance Program | DMS-653 |
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 Claim Form ? You may print this version for use in charts and electronic billing documentation; however, if you submit a paper claim for billing, you must use the red-ink version (see Red-ink Claim Forms above.) | EPSDT-DMS-694 |
EPSDT Provider Agreement | DMS-831 |
Evaluation Form Lower-Limb | DMS-646 |
Explanation of Check Refund | EDS-CR-002 |
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 |
Individual Renewal Form for DDTCS Therapists & School Based Therapists | DMS-0663 |
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 |
NPI Reporting Form | DMS-683 |
Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21 Prescription/Referral | DMS-640 |
Personal Care Assessment and Service Plan | DMS-618 |
Prescription & Prior Authorization Request For Nutrition Therapy & Supplies | DMS-2615 |
Prescription Drug Prior Authorization and Extension of Benefits Request Form | DMS-2694 |
Primary Care Physician Managed Care Program Referral Form | DMS-2610 |
Primary Care Physician Participation Agreement | DMS-2608 |
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 Application | DMS-652 |
Provider Communication Form | AAS-9502 |
Provider Enrollment Application and Contract Package | AppMaterial |
Referral for Certification of Need Medicaid Inpatient Psychiatric Services for Under Age 21 | DMS-2634 |
Referral for Medical Assistance | DMS-630 |
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 Beneficiaries Under Age 21 | DMS-602 |
Request For Orthodontic Treatment | DMS-32-0 |
Request for Private Duty Nursing Services Prior Authorization and Prescription - Initial Request or Recertification | DMS-2692 |
Request for Targeted Case Management Prior Authorization for Beneficiaries Under Age 21 | DMS-601 |
Sterilization Consent Form | DMS-615 English DMS-615 Spanish |
Sterilization Consent Form - Information for Men | PUB-020 |
Sterilization Consent Form - Information for Women | PUB-019 |
Upper-Limb Prosthetic Prescription | DMS-649 |
Vendor Performance Report | None |
Verification of Medical Services | DMS-2618 |
In order by form number:
AAS-9502 | DMS-2685 | DMS-650 |
AAS-9565 | DMS-2687 | DMS-651 |
Address Change | DMS-2692 | DMS-652 |
AFMC-101 | DMS-2694 | DMS-653 |
AFMC-102 | DMS-2698 | DMS-671 |
AFMC-103 | DMS-32-A | DMS-673 |
AFMC-201 | DMS-32-O | DMS-679 |
AFMC-RBSS | DMS-601 | DMS-683 |
Authorization for | DMS-602 | DMS-686 |
Automatic Deposit | DMS-612 | DMS-693 |
CMS-485 | DMS-615 | DMS-694 chart version |
CSPC-EPSDT | DMS-616 | DMS-694 sample |
DCO-645 | DMS-618 | DMS-699 |
DDS/FS#0001.a | DMS-619 | DMS-831 |
DMS-0663 | DMS-628 | ECSE-R |
DMS-2606 | DMS-630 | EDS-AR-004 |
DMS-2608 | DMS-632 | EDS-CI-003 |
DMS-2609 | DMS-633 | EDS-CR-002 |
DMS-2610 | DMS-635 | EDS-MFR-001 |
DMS-2615 | DMS-638 | MAP-8 |
DMS-2618 | DMS-640 | Performance Report |
DMS-2633 | DMS-646 | Provider Enrollment |
DMS-2634 | Application and Contract | |
DMS-2635 | DMS-647 DMS-648 | Package |
DMS-2647 | DMS-649 | PUB-019 |
PUB-020 |
Arkansas Medicaid Contacts and Links
Click the link to view the information.
American Hospital Association
Americans with Disabilities Act Coordinator
APS Healthcare Midwest (APS)
Arkansas Department of Education, Health and Nursing Services Specialist
Arkansas Department of Education, Special Education
Arkansas DHHS Division of Human Services - Aging and Adult Services
Arkansas DHHS Division of Human Services ? Appeals and Hearings Section
Arkansas DHHS Division of Human Services, Child Care and Early Childhood Education, Child Care Licensing Unit
Arkansas DHHS Division of Human Services, Children and Family Services, Contracts Management Unit
Arkansas DHHS Division of Human Services, Children's Services
Arkansas DHHS Division of Human Services, County Operations - Customer Assistance Section
Arkansas DHHS Division of Human Services, Medical Services
Arkansas DHHS Division of Human Services, Medical Services Dental Care Unit
Arkansas DHHS Division of Human Services, Medical Services Director
Arkansas DHHS Division of Human Services, Medical Services Financial Activities Unit
Arkansas DHHS Division of Human Services, Medical Services Hearing Aid Consultant
Arkansas DHHS Division of Human Services, Medical Services Medical Assistance Unit
Arkansas DHHS Division of Human Services, Medical Services Pharmacy Unit-Utilization Review Section
Arkansas DHHS Division of Human Services, Medical Services Third-Party Liability Unit
Arkansas DHHS Division of Human Services, Medical Services UR Benefit Extension Requests Section
Arkansas DHHS Division of Human Services, Medical Services UR/Home Health Extensions
Arkansas DHHS Division of Human Services, Medical Services Utilization Review Section
Arkansas DHHS Division of Human Services, Medical Services Visual Care Coordinator
Arkansas DHHS Division of Human Services, Medical Services, Provider Reimbursement Unit
Arkansas DHHS, Division of Health
Arkansas DHHS, Division of Health, Health Facility Services
Arkansas DHHS, Division of Human Services, Accounts Receivable
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
ConnectCare Helpline
County Codes
CPT Ordering Information
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 Beneficiary Notification of Denied ARKids First-B Claim
Example of Beneficiary 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 Care Declarations
ICD-9-CM Ordering Information
Immunizations Registry Help Desk ? DHHS Division of Health
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
Select Optical
Standard Register
Table of Desirable Weights
U.S. Government Printing Office
Vendor Performance Report
Instructions for Completion of Request for Extension of Benefits ? DMS-699 (Rev.4/07)
All Required Fields of Form DMS-699 Must be Correctly Completed by Entering
The Following Information
Enter Provider Name, Address, City, State, Zip Code ? REQUIRED
Enter Patient?s Full Name ? REQUIRED
Enter Patient?s Address, City, State, Zip Code ? If Available
Enter Patient?s Arkansas Medicaid ID Number, Birth Date, and Sex ? REQUIRED
Enter Diagnoses -Primary to Request First- Then Additional if Applicable ? REQUIRED
Enter Correct Medicaid Procedure Code for Items Requested for Extension ? REQUIRED
Enter Correct ?Type of Service Code? or All Applicable Modifiers (After 07/01/07) ? REQUIRED
Enter From Date of Service ? REQUIRED
Enter To Date of Service ? REQUIRED
Enter Correct Number of Units Being Requested ? REQUIRED
Enter Provider ID Number ? REQUIRED
Enter Provider Taxonomy Code - if Applicable
Complete with an Original Signature by Provider or Provider?s Authorized Representative -REQUIRED
ATTACH A SUMMARY AND MEDICAL RECORDS AS NEEDED TO JUSTIFY MEDICAL NECESSITY ? REQUIRED
Instructions for Completion of the EPSDT Claim Form ? DMS-694
EDS 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 a Child Health Services (EPSDT) screening service, use the claim form DMS-694. The numbered items correspond to numbered fields on the claim form. The DMS-694 is used as a combined referral, screening results document and a billing form. Each screening should be billed separately, providing the appropriate information for each of the screening components. The following numbered items correspond to numbered fields on the claim form.
Medical services such as immunizations and laboratory procedures may also be billed on the DMS-694 when provided in conjunction with a Child Health Services (EPSDT) screening, as well as other treatment services provided.
The following instructions must be read and carefully adhered to, so that EDS can efficiently process claims. Accuracy, completeness and clarity are important. Claims cannot be processed if applicable information is not supplied or is illegible. Claims should be typed whenever possible.
Completed claim forms should be forwarded to the EDS Claims Department. View or print the EDS Claims Department 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 |
1. Patient?s Last Name | Enter the patient?s last name. |
2. Patient?s First Name | Enter patient?s first name. |
3. Patient?s Middle Initial | Enter patient?s middle initial. |
4. Patient?s Sex | Check ?M? for male or ?F? for female. |
5. Patient?s Medicaid ID No. | Enter the entire 10-digit patient Medicaid identification number. |
6. Casehead?s Name | Enter the casehead name for TEA children only. Patient?s name has been requested in Blocks 1, 2 and 3. |
7. County of Residence | Enter the patient?s county of residence. |
8. Date of Birth | Enter the patient?s date of birth in month and year format as it appears on the Medicaid identification card. |
9. Street Address | Enter the patient?s street address. |
10. City | Enter the patient?s city of residence. |
11. If a Patient is a Referral Enter Name of Referring Physician Provider Identification Number/Taxonomy Code | If the patient is a referral, enter the name of the referring physician and his or her provider identification number and taxonomy code. |
12. Medical Record Number | This is an optional entry that the provider may use for accounting purposes. Enter the patient?s account number, if applicable. Up to 16 numeric or alpha characters will be accepted. This number will appear on the Remittance Advice (RA) and is a method of identifying payment of the claim. |
13. Provider Phone Number Pay To: Provider Name and Address Pay To: Provider Number | Enter the provider?s complete name, address, provider identification number, and taxonomy code. If a clinic billing is involved, use the clinic provider identification number. Telephone number is requested but not required. |
14. Other Health Insurance Coverage (Enter Name of Plan and Policy Number) | If applicable, enter the name of the insurance plan and the policy number of any health insurance coverage carried by the patient other than Medicaid. The patient?s Medicaid identification card should indicate ?Yes? if other coverage is carried by the beneficiary. |
15. Was Condition Related to: | |
A. Patient?s Employment | Check ?Yes? if the patient?s condition was employment related. If the condition was not employment related, check ?No.? |
B. An Accident | Check ?Yes? if the patient?s condition was related to an accident. Check ?No? if the condition was not accident related. |
16. Primary Diagnosis or Nature of Injury | Enter the description of the primary reason for treatment of the patient. |
Diagnosis Code | Enter the ICD-9-CM Code that identifies the primary diagnosis. |
18. Type of Screen Periodic Interperiodic | Not required for Medicaid. Completed by Human Services, if applicable. |
SECTION II | |
20. Examination Report | To be completed by screening provider at time of screen. |
A. Basic Screening | |
Item A, Numbers 1 through 6 | Check ?Normal? or ?Abnormal? for each component. Check ?Counseled,? ?Treated? or ?Referred? as applicable. |
Item A, Number 7 | Give results of the lab tests performed at the time of screen. |
Item B | Immunization status appropriate for age and health history. If immunization cannot be performed, note the reason along with the return appointment in ?Comments? section. |
Item C | Enter any other services rendered. |
21. Comments | Briefly explain any problems identified and describe treatment or referral. If referred, indicate the name of the provider to whom the referral was made. |
22. A. Date of Service | Enter the ?from? and ?to? dates of service for each service provided in MM/DD/YY format. A single date of service need not be entered twice on the same line. |
B. Place of Service | Enter the appropriate place of service code. See Section 242.200 for codes. |
C. Fully Describe Procedures, Medical Services or Supplies Furnished For Each Date Given (Explain Unusual Services or Circumstances) | Enter the appropriate HCPCS, CPT and state assigned procedure code and describe any services or circumstances, e.g., what age periodicity screen has been provided and describe procedures performed (including screen, lab test, immunizations, etc.). |
Procedure Code (Identify) | |
D. Diagnosis Code | Enter the ICD-9-CM code, which corresponds with the procedures performed. |
E. Charges | Enter the charges for the rendered services. These charges should be the provider?s current usual and customary fee to private clients. |
F. Days or Units | Enter days or units of service rendered. |
G. Performing Provider Number | If the billing provider noted in Block 13 is a clinic or group, enter the attending provider?s provider identification number and taxonomy code. |
23. Total Charges | Enter the total of Column 22E. This block should contain a sum of charges for all services indicated on the claim form. |
24. Covered by Insurance | Enter the total amount of funds received from other sources. The source of payment should be indicated in Block 14. If payment was received from the patient, indicate in Block 14, but DO NOT include the amount in Block 24. |
25. Balance Due | Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge. |
26. Provider?s Signature | The provider or designated authorized individual must sign the claim certifying that the services were personally rendered by the provider or under the provider?s direction. Provider?s signature? is defined as the provider?s actual signature, a rubber stamp of the provider?s signature, a typewritten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. |
27. Billing Date | Enter date signed. |
Instructions for Completion of Request for Extension of Benefits ? DMS-699 (Rev.4/07)
All Required Fields of Form DMS-699 Must be Correctly Completed by Entering
The Following Information
Enter Provider Name, Address, City, State, Zip Code ? REQUIRED
Enter Patient?s Full Name ? REQUIRED
Enter Patient?s Address, City, State, Zip Code ? If Available
Enter Patient?s Arkansas Medicaid ID Number, Birth Date, and Sex ? REQUIRED
Enter Diagnoses -Primary to Request First- Then Additional if Applicable ? REQUIRED
Enter Correct Medicaid Procedure Code for Items Requested for Extension ? REQUIRED
Enter Correct ?Type of Service Code? or All Applicable Modifiers (After 07/01/07) ? REQUIRED
Enter From Date of Service ? REQUIRED
Enter To Date of Service ? REQUIRED
Enter Correct Number of Units Being Requested ? REQUIRED
Enter Provider ID Number ? REQUIRED
Enter Provider Taxonomy Code - if Applicable
Complete with an Original Signature by Provider or Provider?s Authorized Representative -REQUIRED
ATTACH A SUMMARY AND MEDICAL RECORDS AS NEEDED TO JUSTIFY MEDICAL NECESSITY ? REQUIRED
Field Name and Number | Instructions for Completion |
C. Fully Describe Procedures, Medical Services or Supplies Furnished For Each Date Given (Explain Unusual Services or Circumstances) | Enter the appropriate HCPCS, CPT and state assigned procedure code and describe any services or circumstances, e.g., what age periodicity screen has been provided and describe procedures performed (including screen, lab test, immunizations, etc.). |
Procedure Code (Identify) | |
D. Diagnosis Code | Enter the ICD-9-CM code, which corresponds with the procedures performed. |
E. Charges | Enter the charges for the rendered services. These charges should be the provider?s current usual and customary fee to private clients. |
F. Days or Units | Enter days or units of service rendered. |
G. Performing Provider Number | If the billing provider noted in Block 13 is a clinic or group, enter the attending provider?s provider identification number and taxonomy code. |
23. Total Charges | Enter the total of Column 22E. This block should contain a sum of charges for all services indicated on the claim form. |
24. Covered by Insurance | Enter the total amount of funds received from other sources. The source of payment should be indicated in Block 14. If payment was received from the patient, indicate in Block 14, but DO NOT include the amount in Block 24. |
25. Balance Due | Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge. |
26. Provider?s Signature | The provider or designated authorized individual must sign the claim certifying that the services were personally rendered by the provider or under the provider?s direction. Provider?s signature? is defined as the provider?s actual signature, a rubber stamp of the provider?s signature, a typewritten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. |
27. Billing Date | Enter date signed. |
InstruInsctions for Completion of Prior Authorization Request for Medical Equipment Form SECTION A - TO BE COMPLETED BY THE PROVIDER
REVIEW TYPE: | Indicate the type of prior authorization request: initial, recertification, modification to a current authorization, or extension of benefits. |
DATE(S) OF SERVICE REQUESTED: | Enter the requested date(s) of service. |
PROVIDER INFORMATION: | Enter the provider name, address, provider identification number and taxonomy code, telephone number, and contact person. |
PATIENT INFORMATION: | Enter the beneficiary's full name (Last, First, MI), ten-(10) digit Medicaid ID number, mailing address, date of birth (MM/DD/YYYY), and sex (male or female). |
PHYSICIAN INFORMATION: | Enter the prescribing physician's name, provider identification number, and taxonomy code. |
PROCEDURE CODES: | List all procedure codes (including any modifier(s) for items ordered that require authorization. (Procedure codes that do not require authorization should not be listed.) Enter the number of units requested and a narrative description for each item ordered. |
PERSON SUBMITTING REQUEST: | The person submitting the request must sign and date, verifying the attestation in this section. |
SECTION B - TO BE COMPLETED BY THE PHYSICIAN
EST. LENGTH OF NEED: | Enter the estimated length of need (the length of time the physician expects the patient to require use of the ordered item) by filling in the appropriate number of weeks or months or indicate permanent if the physician expects that the patient will require the item for the duration of his/her life. |
EPSDT REFERRAL: | If applicable, indicate if the request is being made as the result of an EPSDT referral. |
HEIGHT & WEIGHT: | Enter the beneficiary?s current height measured in inches and weight measured in pounds. |
DIAGNOSIS & ICD-9 CODES: | In the first space, list the diagnosis & ICD9 code that represents the primary reason for ordering this item. List any additional diagnosis & ICD9 codes that would further describe the medical need for the item (up to 3 codes). |
QUESTION SECTION: | Answer the question by checking the appropriate ?YES? or ?NO? box. |
MEDICAL NECESSITY: | The physician must document medical necessity for the requested services and sign/date in the space indicated. Signature and date stamps are not acceptable. |
**PRESCRIPTION: | A written prescription MUST be submitted with all requests. This can be documented on the request form or a separate prescription may be attached. |
**LETTER OF MEDICAL NECESSITY: | If the information provided on the request form is insufficient to justify the requested items, a letter of medical necessity from the prescribing physician WILL be required. |
Note: Attach copies of Medical Records/Supporting Documentation substantiating medical necessity of requested services/procedures.
[Instructions for requesting extension of benefits and completion of this form are included on the reverse side of this form.] Comments:
Requirements for Requests for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services
Procedural Policy
To reduce delays in processing requests and to avoid returning requests due to incomplete and/or lack of
documentation, the following procedures must be followed.
016.06.07 Ark. Code R. 022