016-06-08 Ark. Code R. § 32
Claim Forms
Red-inkClaim 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 PROVIDERS 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 |
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 |
Practitioner Identification Number Request Form | DMS-7708 |
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 |
Procedure Code/NDC Detail Attachment Form | DMS-664 |
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 Data Sharing Agreement- Medicare Parts C & D | DMS-652-A |
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-2606 | DMS-602 | DMS-650 | DMS-699 |
AAS-9565 | DMS-2608 | DMS-612 | DMS-651 | DMS-7708 |
Address | DMS-2609 | DMS-615 | DMS-652 | DMS-831 |
Change | DMS-2610 | DMS-616 | DMS-652-A | ECSE-R |
AFMC-101 | DMS-2615 | DMS-618 | DMS-653 | EDS-AR-004 |
AFMC-102 | DMS-2618 | DMS-619 | DMS-664 | EDS-CI-003 |
AFMC-103 | DMS-2633 | DMS-628 | DMS-671 | EDS-CR-002 |
AFMC-RBSS | DMS-2634 | DMS-630 | DMS-675 | EDS-MFR-001 |
Authorization for Automatic | DMS-2635 | DMS-632 | DMS-673 | MAP-8 |
Deposit | DMS-2647 | DMS-633 | DMS-679 | Report |
CMS-485 | DMS-2685 | DMS-635 | DMS-683 | Provider |
CSPC-EPSDT | DMS-2687 | DMS-638 | DMS-686 | Enrollment |
DCO-645 | DMS-2692 | DMS-640 | DMS-689 | Application and Contract |
DDS/FS#0001.a | DMS-2698 | DMS-646 | DMS-693 | Package |
DMS-0101 | DMS-32-A | DMS-647 | DMS-694 chart | PUB-019 |
DMS-0685-14 | DMS-32-0 | DMS-648 | version | PUB-020 |
DMS-0688 | DMS-601 | DMS-649 | DMS-694 sample |
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
Child Health Services (EPSDT)
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
QSource of Arkansas
Select Optical
Standard Register
Table of Desirable Weights
U.S. Government Printing Office
Vendor Performance Report
016.06.08 Ark. Code R. § 032