016-06-08 Ark. Code R. § 23

Current through Register Vol. 49, No. 6, June, 2024

Rule 016.06.08-023 - Section I and Section V Provider Manual Update

105.100 Alternatives for Adults with Physical Disabilities

The Alternatives for Adults with Physical Disabilities (APD) waiver program is for disabled individuals age 21 through 64 who receive Supplemental Security Income (SSI) or who are Medicaid eligible by virtue of their disability and who, but for the services provided by the waiver program, would require a nursing facility level of care.

APD eligibility requires a determination of categorical eligibility, a level of care determination, the development of a plan of care, and a cost comparison to determine the cost-effectiveness of the plan of care. The beneficiary must be notified that he/she may choose either home and community-based services or institutional services.

The services offered through the waiver are:

A. Environmental accessibility/adaptations/adaptive equipment

B. Attendant care

These services are available only to individuals who are eligible under the waiver's conditions. Detailed information is found in the APD provider manual.

131.000Charges that Are Not the Responsibility of the Beneficiary

Except for cost-sharing responsibilities outlined in sections 133.000- 135.000, a beneficiary is not liable for the following charges:

A. A claim or portion of a claim denied for lack of medical necessity.

B. Charges in excess of the Medicaid maximum allowable rate.

C. A claim or portion of a claim denied due to provider error.

D. A claim or portion of a claim denied because of errors made by DMS or EDS.

E. A claim or portion of a claim denied due to changes made in state or federal mandates after services were performed.

F. A claim or portion of a claim denied because a provider failed to obtain prior, concurrent or retroactive authorization for a service.

G. The difference between the beneficiary Medicaid cost sharing responsibility, if any, and the Medicare or Medicare Advantage co-payments.

H. Medicaid pays the difference, if any, between the Medicaid maximum allowable fee and the total of all payments previously received by the provider for the same service. Medicaid beneficiaries are not responsible for deductibles, copayments or co-insurance amounts to the extent that such payments, when added to the amounts paid by third parties equal or exceed the Medicaid maximum for that service, even if the Medicaid payment is zero. The beneficiary is responsible for paying applicable Medicaid cost share amounts.

I. The beneficiary is not responsible for insurance cost share amounts if the claim is for a Medicaid-covered service by a Medicaid-enrolled provider who accepted the beneficiary as a Medicaid patient. Arkansas Medicaid pays the difference between the amount paid by private insurance and the Medicaid maximum allowed amount. Medicaid will not make any payment if the amount received from the third party insurance is equal to or greater than the Medicaid allowable rate.

If an individual who makes payment at the time of service is later found to be Medicaid eligible and Medicaid is billed, the individual must be refunded the full amount of his or her payment for the covered service(s). If it is agreeable with the individual, these funds may be credited against unpaid non-covered services and Medicaid cost-sharing amounts that are the responsibility of the beneficiary.

The beneficiary may not be billed for the completion and submission of a Medicaid claim form.

Exception: Medicaid does not cover the deductible, co-payments or other cost share amounts levied to Medicare Part D drugs.

132.000Charges that are the Responsibility of the Beneficiary

A beneficiary is responsible for:

A. charges incurred during a time of ineligibility

B. charges for non-covered services, including services received in excess of Medicaid benefit limitations, if the beneficiary has chosen to receive and agreed to pay for those non-covered services

C. charges for services which the beneficiary has chosen to receive and agreed to pay for as a private pay patient

D. spend down liability on the first day of spend down eligibility

E. The beneficiary is also responsible for any applicable cost-sharing amounts such as premiums, deductibles, coinsurance, or co-payments imposed by the Medicaid Program pursuant to 42 C.F.R. §§ 447.50- 447.60 (2004). These cost-sharing responsibilities are outlined in sections 124.210 -124.230 and 133.000 -135.000 of this manual.

The beneficiary is not responsible for insurance cost share amounts if the claim is for a Medicaid-covered service by a Medicaid-enrolled provider who accepted the beneficiary as a Medicaid patient. Arkansas Medicaid pays the difference between the amount paid by private insurance and the Medicaid maximum allowed amount. Medicaid will not make any payment if the amount received from the third party insurance is equal to or greater than the Medicaid allowable rate.

142.100General Conditions

A. Each provider must be licensed, certified or both, as required by law, to furnish all goods or services that may be reimbursed by the Arkansas Medicaid Program.

B. Providers must comply with applicable standards for professional and quality care.

C. It is the responsibility of each provider to read the Arkansas Medicaid provider manual provided by DMS and to abide by the rules and regulations specified in the manual.

D. All services provided must be medically necessary. The beneficiary is not liable for a claim or portion of a claim when the Medicaid Program, either directly or through a designee, determines that the services were not medically necessary.

E. Services will be provided to qualified beneficiaries without regard to race, color, national origin or disability within the provisions of Title VI of the Federal Civil Rights Act, Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990.

F. Each provider must notify the Medicaid Provider Enrollment Unit in writing immediately regarding any changes to its application or contract, such as:

1. Change of address (View or print form DMS-673 - Address Change Form.)

2. Change in members of group, professional association or affiliations*

3. Change in practice or specialty*

4. Change in Federal Employer Identification Number (FEIN)*

5. Retirement or death of provider*

6. Complete change of ownership (View or print form DMS-688 - Provider Change of Ownership Information Form.)

7. Change in Ownership Control (5% or more) or Conviction of Crime (View or print form DMS-675 Ownership and Conviction Disclosure.)

8. Disclosure of Significant Business Transactions (View or print form DMS-689 - Disclosure of Significant Business Transactions.)

Changes in items two (2) through five (5) above may be properly addressed through a provider's original signature letter of explanation and the appropriately corrected pages of the provider application document. (View or print form DMS-652- Provider Application Form.)

G. Except for Medicaid covered services and other professional services furnished in exchange for the provider's usual and customary charges, a Medicaid provider may not knowingly give, offer, furnish, provide or transfer money, services or any thing of value for less than fair market value to any Medicaid beneficiary, to anyone related to any Medicaid beneficiary within the third degree or any person residing in the household of a beneficiary.

This rule does not apply to:

1. Pharmaceutical samples provided to a physician at no cost or to other comparable circumstances where the provider obtains the sample at no cost and distributes the samples without regard to Medicaid eligibility.

2. Provider actions taken under the express authority of state or federal Medicaid laws or rules or the provider's agreement to participate in the Medicaid Program.

142.400Conditions Related to Disclosure

142.410Disclosures of Ownership and Control

A. The Division of Medical Services (DMS) requires that providers disclose the following information regarding direct or indirect ownership and control interest as a condition of participation in the Medicaid Program (View or print Ownership and Conviction Disclosure form (DMS-675).

1. The name and address of each person with a direct or indirect ownership or control interest in the disclosing entity or in any subcontractor in which the disclosing entity has direct or indirect ownership of five percent (5%) or more.

2. In compliance with information shown above, the provider must also disclose if any person named above is related to another as a spouse, parent, child or sibling.

3. The name of any other disclosing entity in which a person with a direct or indirect ownership or control interest in the disclosing entity also has a direct or indirect ownership or control interest. This requirement applies to the extent that the disclosing entity can obtain this information by requesting it in writing from the person. The disclosing entity must:

a. Keep copies of all these requests and the responses to them;

b. Make them available to representatives of the Secretary of Health and Human Services or to the Division of Medical Services upon request, and

c. Advise DMS when there is no response to a request.

B. Any disclosing entity that is subject to periodic survey and certification of its compliance with Medicaid standards must supply the information specified above to representatives of an Arkansas survey agency at the time of a survey. The survey agency must promptly furnish the information to the Secretary of Health and Human Services and to the Division of Medical Services.

C. Any disclosing entity that is not subject to periodic survey and certification and has not supplied the information specified above to the Secretary of Health and Human Services within the prior twelve month period, must submit the information to the Division of Medical Services before entering into a contract or agreement to participate in the program.

142.420Disclosures of Information Regarding Personnel Convicted of

Crime

Before the Division of Medical Services enters into or renews a provider agreement, or at any time upon written request by DMS, the provider must disclose to DMS the identity of any person who:

A. Has direct or indirect ownership or control interest in the provider, or is an agent or managing employee of the provider and

B. Has ever been convicted of a criminal offense. View or print Ownership and Conviction Disclosure form (DMS-675).

142.430 Disclosures of Business Transactions

A provider must submit full, accurate and complete information regarding:

A. The ownership of any subcontractor with whom the provider has business transactions totaling more than $25,000 or five percent (5%) of the provider's total operating expenses during the 12-month period immediately prior to the date of application or application renewal, and

B. Any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the five-year period ending on the date of the application or application renewal.

C. Beginning on the effective date of enrollment in the Arkansas Medicaid Program, ongoing full and complete disclosure must be submitted concerning any significant business transactions (see definition on instruction page of DMS-689) that occur between the named entity and subcontractor or wholly owned supplier. This information must be submitted to Arkansas Medicaid, Provider Enrollment, within 35 days of the date the transaction takes place (View or print form DMS-689, Disclosure of Significant Business Transactions).

171.100PCP-Qualified Physicians and Single-Entity Providers

A. PCP-qualified physicians are those whose sole or primary specialty is

1. Family Practice

2. General Practice

3. Internal Medicine

4. Obstetrics and gynecology

B. Obstetricians and gynecologists may choose whether to be PCPs.

All other PCP-qualified physicians and clinics must enroll as PCPs, except for physicians who certify in writing that they are employed exclusively by an Area Health Education Center (AHEC), a Federally Qualified Health Center (FQHC), a Medical College Physicians Group, or a hospital (i.e., they are "hospitalists" and they practice exclusively in a hospital).

1. Pediatrics and Adolescent Medicine

C. Physicians with multiple specialties may elect to enroll as PCPs if a secondary or tertiary specialty in their Medicaid provider file is listed in part C above.

D. PCP-qualified clinics and health centers (single-entity PCPs) are

1. AHECs

2. FQHCs

3. The family practice and internal medicine clinics at the University of Arkansas for Medical Sciences

American Hospital Association
Telephone	(312)422-3390
Mailing address	American Hospital Association National Uniform Billing Committee One North Franklin, 29 Floor Chicago, IL 60606
Web site	http //www.nubc.org
Americans with Disabilities Act Coordinator
TTY-Hearing Impaired -To access any number listed.	800-877-8973 - Voice Relay
Local	(501)682-8323
Toll free	(800) 482-5850, extension 2-8323
APS Healthcare Midwest (APS)
Toll free	(800)721-4925
Local	(501) 372-2970
Fax	(888)468-9318
Address	APS Healthcare 225 South Pulaski Little Rock, AR 72203
Arkansas Department of Education, Special Education
Telephone	(501)-682-4221
Arkansas Department of Human Services, Accounts Receivable
Telephone	(501)682-6502
Toll free	(800) 482-5850, extension 2-6502
Fax	(501)682-1855
Mailing address	DHS Accounts Receivable PO Box 8181, Slot WG2 Little Rock, AR 72203-8181

Arkansas Department of Human Services, Appeals and Hearings Section
Telephone	682-8622
Toll free	(800) 482-5850, extension 2-8622
Mailing address	Arkansas Department of Human Services Appeals and Hearings Section P.O. Box 1437, Slot N401 Little Rock, AR 72203-1437
Arkansas Department of Human Services, Children's Services
Telephone	(501)682-2277
Toll free	(800) 482-5850, extension 2-2277
Mailing address	Arkansas Department of Human Services Children's Services P.O. Box 1437, Slot S380 Little Rock, AR 72203-1437
Arkansas Department of Human Services, Division of Child Care and Early Childhood Education, Child Care Licensing Unit
Telephone	(501)682-8590
Toll free	(800) 482-5850, extension 2-8590
Mailing address	Arkansas Department of Human Services Division of Child Care and Early Childhood Education Child Care Licensing Unit P.O. Box 1437, Slot S150 Little Rock, AR 72203-1437
Arkansas Department of Human Services, Division of Children and Family Services, Contracts Management Unit
Telephone	(501)682-9978
Toll free	(800) 482-5850, extension 2-9978
Mailing address	Arkansas Department of Human Services Division of Children and Family Services Contracts Management Unit P.O. Box1437-SlotS561 Little Rock, AR 72203-1437
Arkansas Department of Health
Toll free	(800) 462-0599
Telephone	(501)661-2000

Arkansas Department of Health, Health Facility Services
Telephone	(501)661-2201
Mailing address	HCFA CLIA Program Arkansas Department of Health Health Facility Services 5800 West 10th, Suite 400
	Little Rock, AR 72204
Arkansas Department of Human Services, Division of Medical Services
Mailing address	Arkansas Department of Human Services Division of Medical Services P.O. Box 1437, Slot S413 Little Rock, AR 72203-1437
Arkansas Department of Human Services, Division of Medical Services, Provider Reimbursement Unit
Telephone	(501)682-8308
Toll free	(800) 482-5850, extension 2-8308
Fax	(501)682-3889
Mailing address	Arkansas Department of Human Services Division of Medical Services Provider Reimbursement Unit P.O. Box 1437, Slot S416 Little Rock, AR 72203-1437
Hours	8 00 AM through 4 30 PM, Monday through Friday, except for holidays
Arkansas DHS, Division of Medical Services, Benefit Extension Requests, UR Section
Telephone	(501)682-8340
Toll free	(800) 482-5850, extension 2-8340
Mailing address *Home Health Incontinence Supplies *Personal Care *Private Duty Nursing *Supplies for Under Age 21 yrs *Wheelchairs and Repairs	DHS Division of Medical Services Benefit Extension Requests - *lnsert type from list at left P.O. Box 1437, Slot S413 Little Rock, AR 72203-1437

Arkansas DHS, Division of Medical Services, Dental Care Unit
Toll free	(800) 482-5850, extension 2-8336
Telephone	(501)682-8336 (501)682-8332 (501)682-8297
Mailing address	DHS Division of Medical Services Dental Care Unit P.O. Box 1437, Slot S410 Little Rock, AR 72203-1437
Arkansas DHS, Division of Medical Services, Director
Telephone	(501)682-8292
Toll free	(800) 482-5850, extension 2-8292
Mailing address	DHS Division of Medical Services Director P.O. Box 1437, Slot S401 Little Rock, AR 72203-1437
Arkansas Division of Medical Services, EDS Provider Enrollment Unit
Toll free	1-800-457 -4454
Local and out of state	(501)376-2211
Fax	(501) 374-0746
Mailing address	Medicaid Provider Enrollment Unit EDS P.O. Box 8105 Little Rock, AR 72203-8105
Arkansas DHS, Division of Medical Services, Financial Activities Unit
Telephone	(501)682-8308
Toll free	(800) 482-5850, extension 2-8308
Mailing address	DHS Division of Medical Services Financial Activities Unit P.O. Box 1437, Slot S416 Little Rock, AR 72203-1437
Arkansas DHS Division of Medical Services, Hearing Aid Consultant
Telephone	(501)682-8340
Toll free	(800) 482-5850, extension 2-8340
Mailing address	DHS Division of Medical Services Hearing Aid Consultant P.O. Box 1437; Slot S413

	Little Rock, AR 72203
Arkansas DHS, Division of Medical Services, Medical Assistance Unit
Toll free	(800)482-5850, extension 2-8301
Telephone	(501)682-8301
Mailing address	DHS Division of Medical Services Medical Assistance Unit P.O. Box 1437, Slot S410 Little Rock, AR 72203-1437
Arkansas DHS Division of Medical Services, Pharmacy Unit
Telephone	(501)683-4120
Toll free	(800) 482-5850, extension 3-4120
Mailing address	DHS Division of Medical Services Pharmacy Unit P.O. Box 1437, Slot S415 Little Rock, AR 72203-1437
Arkansas DHS, Division of Medical Services, Program Communications Unit
Telephone	(501)682-8315
Toll free	1-800-482-5850, extension 2-8315
Mailing address	DHS Division of Medical Services Program Communications Unit P.O. Box 1437, Slot S410 Little Rock, AR 72203-1437
Hours	8 00 AM through 4 30 PM, Monday through Friday, except for holidays
Arkansas DHS, Division of Medical Services, Third-Party Liability Unit
Telephone	(501)682-6711
Toll free	(800) 482-5850, extension 2-6711
Fax	(501)682-1644
Mailing address	DHS Division of Medical Services TPL Unit P.O. Box 1437, Slot S296 Little Rock, AR 72203-1437

Arkansas DHS, Division of Medical Services, Utilization Review Section
Toll free	1-800-482-5850, extension 2-8340
Telephone	(501)682-8340
Fax	(501)682-8013
Mailing address	Arkansas DHS Division of Medical Services Utilization Review Section P.O. Box 1437, Slot S413 Little Rock, AR 72203-1437
Arkansas DHS, Division of Medical Services, UR/Home Health Extensions
Telephone	(501)682-6670
Toll free	(800) 482-5850, extension 2-6670
Fax	(501)(501)682-8013
Mailing address	DHS Division of Medical Services UR/Home Health Extensions P.O. Box 1437, Slot S413 Little Rock, Arkansas 72203-1437
Arkansas DHS, Division of Medical Services, Visual Care Coordinator
Toll free	(800) 482-5850, extension 2-8342
Telephone	(501)682-8342
Fax	(501) 682-8304
Arkansas Foundation for Medical Care
In-state and out-of-state toll free for inpatient reviews only	1-877-650-2362
General telephone contact, local or long distance - Fort Smith	(479) 649-8501
Fax	(479) 649- 0776
Fax for pre-approvals	(479) 649-0776
Mailing address	Arkansas Foundation for Medical Care, Inc. PO Box 180001 Fort Smith, AR 72918-0001
Physical site location	2201 Brooken Hill Drive Fort Smith, AR 72908
Office hours	8 30 a.m. until 5 00 p.m. (Central Time), Monday through Friday, except holidays

Arkansas Hospital Association
Telephone	(501)224-7878
Mailing address	Arkansas Hospital Association 419 Natural Resources Drive Little Rock, Arkansas 72205
ARKids First-B
In-state WATS	1-888-474-8275
Telephone	(501)682-8310
Central Child Health Services Office (EPSDT)
Toll free	(800) 482-5850, extension 2-8323
Telephone	(501)682-8323
Fax	(501)682-1197
Mailing address	AR DHS Division of Medical Services Child Health Services (EPSDT) P.O. Box 1437, Slot S410 Little Rock, AR 72203-1437
Children's Services
Toll free	1-800-482-5850, extension 2-2277 or 2-2270
Telephone	(501)682-2270 (501)682-2277
Fax	(501)682-8247
Mailing address	Arkansas Department of Human Services Children's Services P.O. Box 1437, Slot S380 Little Rock, Arkansas 72203-1437
ConnectCare Helpline
Toll free	1-800-275-1131
Telephone	(501)614-4689
TDD	1-800-285-1131

CPT Ordering
Order the CPT online at http A/vww.ir information below.	iqenixonline.com/or contact Ingenix using the
Telephone	1-877-464-3649
Fax	1-800-982-4033
Mailing address	Ingenix P.O. Box 27116 Salt Lake City, UT 84127-0116
Web site	http //www.inqenixonline.com/
Division of Aging and Adult Services
Telephone	(501) 682-2441
Toll free	(800) 482-5850, extension 2-2441
Adults with Physical Disabilities Waiver Provider Certification mailing address	Division of Aging and Adult Services Adults with Physical Disabilities Waiver Provider Certification P.O. Box 1437, Slot S530 Little Rock, AR 72203-1437
ElderChoices Provider Certification mailing address	Division of Aging and Adult Services ElderChoices Provider Certification P.O. Box 1437, Slot S530 Little Rock, AR 72203-1437
Living Choices Assisted Living application request	Division of Aging and Adult Services Living Choices Assisted Living P.O. Box 1437, Slot S530 Little Rock, AR 72203-1437
Division of County Operations, Customer Assistance Section
In-state WATS	1-800-482-8988
TTY	1-(501) 682-8933
Mailing address	DHS Division of County Operations P.O. Box 1437 Slot S301 Little Rock, AR 72203-1437

EDS Claims Department
Claim Type
Inpatient, Outpatient, Nursing Home Cross-over, Home Health, Dental, Vision	EDS Claims P.O. Box 8033 Little Rock, AR 72203
Physician (CMS -1500), EPSDT, Hearing, and Professional Cross-over	EDS Claims P.O. Box 8034 Little Rock, AR 72203
Claims addressed to attention of Communication's Analyst, Medicaid Request and Adjustment claims	EDS Claims P.O. Box 8036 Little Rock, AR 72203

EDS EDI Support Center (formerly AEVCS Help Desk)
Toll free within Arkansas	1-800-457 -4454
Local and out-of-state	(501)376-2211
Hours	8 00 am to 5 00 pm Monday through Friday except for holidays
EDS observed holidays	New Year's Day Memorial Day Independence Day Labor Day Veterans Day Thanksgiving Day The Friday After Thanksgiving Christmas Eve Christmas Day
After hours, report "continuous busy" and "9999 Host System Error" messages to	(501) 374-6609, extension 290 Monday through Friday, 5 pm to 8 am, and on weekends and holidays If you do not leave a message, no problem report will be registered. Do notuse this number to report claim rejections.
EDS Inquiry Unit
Address	EDS Inquiry Unit P.O. Box 8036 Little Rock, AR 72203

EDS Manual Order
Address	EDS Manual Order PO Box 8036 Little Rock, AR 72203-8036
EDS Pharmacy Help Desk
Toll free within Arkansas	1-800-707-3854
Local or out-of-state	(501) 374-6609, ext. 500
Hours	8 00 AM to 5 00 PM Monday through Friday except for holidays
EDS observed holidays	New Year's Day Memorial Day Independence Day Labor Day Veteran's Day Thanksgiving Day The Friday After Thanksgiving Christmas Eve Christmas Day
Voice Response System (VRS)	1-800-806-6181 Available 24 hours every day
EDS Provider Assistance Center (PAC)
Within Arkansas	1-800-457 -4454
Local or out-of-state	(501)376-2211
PAC mailing address	EDS Provider Assistance Center P.O. Box 8036 Little Rock, AR 72203-8036
Hours	8 00 AM and 4 30 PM Monday through Friday except for holidays
EDS observed holidays	New Year's Day Memorial Day Independence Day Labor Day Veteran's Day Thanksgiving Day The Friday After Thanksgiving Christmas Eve Christmas Day

First Connections Infant & Toddler Program, Developmental Disabilities Services
Mailing address	First Connections Infant & Toddler Program Developmental Disabilities Services P.O. Box 1437, Slot N503 Little Rock, Arkansas 72203-1437
First Health
Toll Free	1-800-770-3084
Fax	1-800-639-8982
Prior Authorization (PA) for Outpatient Mental Health Services for 21 and over Mailing address	First Health Services 4300 Cox Road Glen Allen, VA 20360
Health and Nursing Services Specialist
Telephone Number	(501) 324-9740
Address	Arkansas Department of Education Health and Nursing Services Specialist 2020 West Third, Suite 320 Little Rock, AR 72205
ICD-9-CM, CPT, and HCPCS Reference Book Ordering
You can order the ICD-9-CM, CPT, Awww.inqenixonline.com/or contc	and the HCPCS reference books online at http act Ingenix using the information below.
Telephone	1-877-464-3649
Fax	1-800-982-4033
Mailing address	Ingenix P.O. Box 27116 Salt Lake City, UT 84127-0116
Web site	http //www.inqenixonline.com/
Immunizations Registry Help Desk
In-state and out-of-state toll free	1-800-574-4040

Medicaid Reimbursement Unit Communications Hotline
Toll free	1-800-482-5431
Local or out of state	(501)682-8321
National Supplier Clearinghouse
Toll free	1-803-754-3951
Address	National Supplier Clearinghouse P.O. Box 100142 Columbia, SC 29202-3142
Primary Care Physician (PCP) Enrollment Voice Response System
VRS	1-800-805-1512
Provider Qualifications, Division of Behavioral Health Services
Fax	(501)686-9182
Mailing address	Provider Qualifications Division of Behavioral Health Services 4313 West Markham, Slot 4313 Little Rock, Arkansas 72205-4096
Select Optical
Toll free	1-800-282-6960
Fax	1-800-553-1435
Mailing address	Select Optical 6510 Huntley Road Columbus, OH 43229
Standard Register
Mailing address	Standard Register 1501 North Pierce Street, Suite 105 Little Rock, AR 72207

U.S. Government Printing Office
Toll free	(866)512-1800
Fax	(202)512-2250
Mailing address	Superintendent of Documents P.O. Box 371954 Pittsburgh, PA 15250-7954
Web site	http //bookstore.qpo.qov
E-mail	orders@qpo.qov
Hours	7 30 a.m. -4 30 p.m.

Claim Forms

Red-ink Claim Forms

The following is a list of the red-ink claim forms required by Arkansas Medicaid. The forms below cannot be printed from this manual for use. Information about where to get the forms and links to samples of the forms are available below. To view a sample 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

* For dates of service after 11/30/07 - ALL HOSPICE PROVIDER USE ONLY FORM CMS-1450 (formerly (UB-04) for billing.

** A printable PROVIDER INTEROFFICE DOCUMENTATION ONLY version of this form is available below under Arkansas Medicaid Forms.

Claim Forms

The following is a list of the non-red-ink claim forms required by Arkansas Medicaid. Information about where to get a supply of the forms and links to samples of the forms are available below. To view a sample 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

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 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
Change of Ownership Information	DMS-0688
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
Contact Lens Prior Authorization Request Form	DMS-0101
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
Disclosure of Significant Business Transactions	DMS-689
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
Ownership and Conviction Disclosure	DMS-675
Personal Care Assessment and Service Plan	DMS-618
Prescription & Prior Authorization Request For Nutrition Therapy & Supplies	DMS-2615
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
Prior Authorization (PA) Request for Extension of Benefits-Prescription Drugs	DMS-0685-14
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

AAS-9565

Address Change

AFMC-101

AFMC-102

AFMC-103

AFMC-RBSS

Authorization for Automatic Deposit

CMS-485

CSPC-EPSDT

DCO-645

DDS/FS#0001.a

DMS-0101

DMS-0663

DMS-0685-14

DMS-0688 DMS-2606 DMS-2608 DMS-2609 DMS-2610 DMS-2615 DMS-2618 DMS-2633 DMS-2634 DMS-2635 DMS-2647 DMS-2685 DMS-2687 DMS-2692 DMS-2698 DMS-32-A DMS-32-0

DMS-601 DMS-602 DMS-612 DMS-615 DMS-616 DMS-618 DMS-619 DMS-628 DMS-630 DMS-632 DMS-633 DMS-635 DMS-638 DMS-640 DMS-646 DMS-647 DMS-648

DMS-649

DMS-650

DMS-651

DMS-652

DMS-653

DMS-671

DMS-675

DMS-673

DMS-679

DMS-683

DMS-686

DMS-689

DMS-693

DMS-694 chart version

DMS-694 sample

DMS-699

DMS-831

ECSE-R

EDS-AR-004

EDS-CI-003

EDS-CR-002

EDS-MFR-001

MAP-8

Performance Report

Provider Enrollment Application and Contract Package

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 Department of Human Services - Aging and Adult Services

Arkansas Department of Human Services - Appeals and Hearings Section

Arkansas Department of Human Services, Child Care and Early Childhood Education, Child Care Licensing Unit

Arkansas Department of Human Services, Children and Family Services, Contracts Management Unit

Arkansas Department of Human Services, Children's Services

Arkansas Department of Human Services, County Operations - Customer Assistance Section

Arkansas Department of Human Services, Medical Services

Arkansas Department of Human Services, Medical Services, Dental Care Unit

Arkansas Department of Human Services, Medical Services Director

Arkansas Department of Human Services, Medical Services, Financial Activities Unit

Arkansas Department of Human Services, Medical Services, Hearing Aid Consultant

Arkansas Department of Human Services, Medical Services, Medical Assistance Unit

Arkansas Department of Human Services, Medical Services, Pharmacy Unit-Utilization Review Section

Arkansas Department of Human Services, Medical Services, Program Communications Unit

Arkansas Department of Human Services, Medical Services, Third-Party Liability Unit

Arkansas Department of Human Services, Medical Services, UR Benefit Extension Reguests Section

Arkansas Department of Human Services, Medical Services, UR/Home Health Extensions

Arkansas Department of Human Services, Medical Services, Utilization Review Section

Arkansas Department of Human Services, Medical Services, Visual Care Coordinator

Arkansas Department of Human Services, Medical Services, Provider Reimbursement Unit

Arkansas Department of Health

Arkansas Department of Health, Health Facility Services

Arkansas Department 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 - Arkansas Department 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

016.06.08 Ark. Code R. § 023

8/7/2008