016-06-09 Ark. Code R. § 4
Covered services provided to ARKids First-B beneficiaries are within the same scope of services provided to Arkansas Medicaid ARKids First -A beneficiaries. However, some services are subject to different levels of benefits and cost sharing amounts are applied. Refer to the appropriate Arkansas Medicaid provider manual for the scope of each service covered under the ARKids First Program. See section 221.100 of this manual for a listing of ARKids First-B Medical Care Benefits that indicate restrictions and required co-payment/co-insurance or cost-sharing amounts for covered services.
ARKids First-B beneficiaries receive preventive health care screens and treatment options within covered benefits. ARKids First-B beneficiaries are not entitled to the same benefits as children under the Arkansas Medicaid Child Health Services (EPSDT) Program and may not be billed as an EPSDT screen.
Listed below are the covered services for the ARKids-B program. This chart also includes benefits, whether Prior Authorization or a Primary Care Physician (PCP) referral is required and specifies the cost-sharing requirements.
Program Services | Benefit Coverage and Restrictions | Prior Authorization/ PCP Referral | Co-payment/ Coinsurance/ Cost-Sharing Requirement |
Ambulance (Emergency Only) | Medical Necessity | None | $10 per trip |
Ambulatory Surgical Center | Medical Necessity | PCP Referral | $10 per visit |
Certified Nurse-Midwife | Medical Necessity | PCP Referral | $10 per visit |
Chiropractor | Medical Necessity | PCP Referral | $10 per visit |
Dental Care (No Orthodontia) | Routine dental care | None - PA for inter-periodic screens | $10 per visit |
Durable Medical Equipment | Medical Necessity $500 per state fiscal year (July 1 through June 30) minus the coinsurance/cost-share. Covered items are listed in section 262.120 | PCP Referral and Prescription | 20% of Medicaid allowed amount per DME item cost-share |
Emergency Dept. Ser | vices | ||
Emergency | Medical Necessity | None | $10 per visit |
Non-Emergency | Medical Necessity | PCP Referral | $10 per visit |
Assessment | Medical Necessity | None | $10 per visit |
Family Planning | Medical Necessity | None | None |
Federally Qualified Health Center (FQHC) | Medical Necessity | PCP Referral | $10 per visit |
Home Health | Medical Necessity (10 visits per state fiscal year (July 1 through June 30) | PCP Referral | $10 per visit |
Hospital, Inpatient | Medical Necessity | PA on stays over 4 days if age 1 or over | 20% of first inpatient day |
Hospital, Outpatient | Medical Necessity | PCP referral | $10 per visit |
Immunizations | All per protocol | PCP or Administered by ADH | None |
Laboratory & X-Ray | Medical Necessity | PCP Referral | $10 per visit |
Medical Supplies | Medical Necessity Benefit of $125/mo. Covered supplies listed in section 262.110 | PCP Prescriptions PA required on supply amounts exceeding $125/mo | None |
Mental and Behavioral Health, Outpatient | Medical Necessity | PCP Referral PA on treatment services | $10 per visit |
Nurse Practitioner | Medical Necessity | PCP Referral | $10 per visit |
Physician | Medical Necessity | PCP referral to specialist and inpatient professional services | $10 per visit |
Podiatry | Medical Necessity | PCP Referral | $10 per visit |
Prenatal Care | Medical Necessity | None | None |
Prescription Drugs | Medical Necessity | Prescription | $5 per prescription (Must use generic and rebate manufacturer, if available) |
Preventive Health Screenings | All per protocol | PCP Administration or PCP Referral | None |
Rural Health Clinic | Medical Necessity | PCP Referral | $10 per visit |
Speech Therapy | Medical Necessity 4 evaluation units (1 unit =30 min) per state fiscal year 4 therapy units (1 unit=15 min) daily | PCP Referral Authorization required on extended benefit of services | $10 per visit |
Vision Care | |||
Eye Exam | One (1) routine eye exam (refraction) every 12 months | None | $10 per visit |
Eyeglasses | One (1) pair every 12 months | None | None |
Refer to your Arkansas Medicaid specialty provider manual for prior authorization and PCP referral procedures.
ARKids First-B beneficiary cost-sharing is capped at 5% of the family's gross annual income.
Services Not Covered for ARKids First-B Beneficiaries:
Audiological Services; EXCEPTION, Tympanometry, CPT procedure code 92567, when the diagnosis is within the ICD-9-CM range of 381.0 through 382.9
Child Health Management Services (CHMS)
Child Health Services/Early and Periodic Screening, Diagnosis and Treatment (EPSDT)
Developmental Day Treatment Clinic Services (DDTCS)
Diapers, underpads and incontinence Supplies
Domiciliary Care
End Stage Renal Disease Services
Hearing aids
Hospice
Hyperalimentation
Inpatient Psychiatric Services for Under Age 21
Non-Emergency transportation
Nursing facilities
Occupational and Physical Therapies
Orthodontia
Orthotic Appliances and Prosthetic Devices
Personal Care
Private Duty Nursing Services
Rehabilitation Therapy for Chemical Dependency
Rehabilitative Services for Children
Rehabilitative Services for Persons with Physical Disabilities (RSPD)
School-Based Mental Health Services
Targeted Case Management
Ventilator Services
Only Prosthetics Program and Home Health Program providers may bill for items in the medical supplies category. Refer to Section 262.110 of this manual for a listing of medical supplies covered for ARKids First-B beneficiaries. Medical supplies benefits are $125.00 per month, per beneficiary. The $125.00 may be provided by the Home Health Program, the Prosthetics Program or a combination of the two. However, an ARKids First-B beneficiary may not receive more than a total of $125.00 of supplies per month unless extended benefits have been requested and granted. An extension of the $125.00 per month benefit may be considered when medically necessary. Refer to the respective Arkansas Medicaid Provider Manual for procedures regarding requests for extended benefits for medical supplies.
Durable Medical Equipment (DME) benefit for ARKids First-B beneficiaries is $500.00 per state fiscal year (July 1 through June 30). There is a 20% co-insurance per item. DME may be billed by providers enrolled in the Prosthetics Program.
Refer to Section 262.120 of this manual for a listing of DME items covered by the ARKids First-B Program.
Dental services benefits for ARKids First-B beneficiaries are one periodic dental exam, bite-wing x-rays, and prophylaxis/fluoride treatments every six (6) months plus one (1) day. Scalings are covered once per State Fiscal Year (SFY).
The procedure codes listed in Section 262.150 may be billed for the periodic dental exams, interperiodic dental exams and prophylaxis/fluoride for ARKids First-B beneficiaries.
Refer to Section II of the Medicaid Dental Provider Manual for a complete listing of covered dental services. Procedures for dental treatment services that are not listed as a payable service in the Medicaid Dental Provider Manual may be requested on individual treatment plans for prior authorization review. These individually requested procedures and dental treatment services are subject to determination of medical necessity, review and approval by the Division of Medical Services dental consultants.
Orthodontia Services are not covered for ARKids First-B beneficiaries. 222.400 Vision Care Benefit
One routine eye exam (refraction) every twelve months is covered for ARKids First-B beneficiaries.
Refer to Section II of the Visual Care Provider Manual for a complete listing of covered visual services.
Home Health benefits for ARKids First-B beneficiaries are 10 visits per state fiscal year (July 1 through June 30). The 10 visits may be provided by a registered nurse or licensed practical nurse or a combination of the two. However, an ARKids First-B beneficiary will not have coverage for more than 10 visits per state fiscal year.
Refer to Section II of the Home Health Provider manual for further coverage details and billing procedures.
See section 222.100 regarding benefits for medical supplies.
Speech Therapy services are available to beneficiaries in the ARKids First-B program and must be performed by a qualified, Medicaid participating Speech Therapist. A referral for a speech therapy evaluation and prescribed treatment must be made by the beneficiary's PCP or attending physician if exempt from the PCP program. All therapy services for ARKids First- B beneficiaries require referrals and prescriptions be made utilizing the "Occupational, Physical and Speech Therapy for Medicaid Eligible Recipients Under Age 21" form DMS-640. View or print form DMS-640
Speech therapy referrals and covered services are further defined in the Physicians and in the Occupational, Physical and Speech Therapy Provider Manuals. Physicians and therapists must refer to those manuals for additional rules and regulations that apply to speech therapy services for ARKids First - B beneficiaries.
Arkansas Medicaid applies the following daily therapy benefits to speech therapy services in this program:
The ARKids First-B Program supports preventive medicine for beneficiaries by reimbursing primary care physicians (PCPs) who provide medical preventive health screens and qualified screening providers to whom PCPs refer beneficiaries. ARKids First-B outreach efforts vigorously promote the program's emphasis on preventive medical health care. Beneficiary cost sharing does not apply to covered preventive medical health screens, including those for newborns.
The supplemental eligibility response request to an ARKids First-B beneficiary's identification card will indicate to the provider the date of the beneficiary's last preventive health screen (procedure codes 99381 through 99385; and/or 99391 through 99395). This information should be reviewed and verified, along with the beneficiary's eligibility, prior to performing a service. This information will assist the beneficiary's PCP or preventive health screen provider in determining the beneficiary's eligibility for the service and ensuring that preventive health screens are performed in a timely manner in compliance with the periodicity chart for ARKids First-B beneficiaries.
Newborn screens do not require PCP referral.
Certified nurse-midwives may provide newborn screens ONLY.
Nurse practitioners, in addition to newborn preventive health screens, are authorized to provide other preventive health screens with a PCP referral. Refer to section 262.130 for preventive health screens procedure codes.
A hearing risk assessment is required for all children receiving a periodic complete medical preventive health screen. Medical screening providers must administer an age-appropriate hearing assessment. The age-specific procedures (Sections 222.810 -222.850) may be helpful to determine the necessary procedures according to the child's age. Consult with audiologists or the Department of Education to obtain appropriate procedures to use for screening and methods of administering the risk assessment screens. This screening does not require machine audiology testing. Subjective testing may be provided as part of a hearing screening.
A vision risk assessment is required for all children receiving a complete medical preventive health screen. The age-specific procedures (Sections 222.810 - 222.850) may be helpful to determine the necessary procedures according to the child's age. This screening does not require Titmus machine or other ophthalmological testing. Subjective testing may be provided as part of a vision screening. However, a vision risk assessment does not substitute for a full periodic preventive vision screen through a Medicaid participating vision provider.
A full annual vision screening by a Medicaid participating vision provider is exempt from the PCP referral requirement (see section 222.400 ). When a full annual vision periodicity schedule screen coincides with the schedule for a periodic complete medical preventive health screen, the different screens may not be performed on the same day, or within seven (7) days of each other without claim denial citing duplication of services.
An oral assessment is considered part of the complete medical preventive health screen; however, an oral assessment may not substitute for a full periodic preventive dental examination through a Medicaid dental provider. Assistance with establishing a dental home for the beneficiary is included as part of the medical screen. A PCP referral is not required for dental services provided by a Medicaid participating dentist; see section 222.300 for further details on the dental services available to ARKids First - B beneficiaries. See section 262.150 for procedure codes used by a Medicaid dental provider to bill for ARKids First-B preventive dental services.
The ARKids First - B periodic screening schedule follows the guidelines for the EPSDT screening schedule and is updated in accordance with the recommendations of the American Academy of Pediatrics.
From birth through twelve (12) months of age, children may receive six (6) periodic screens in addition to the newborn screen performed in the hospital.
Children age fifteen (15) months through four (4) years may receive five (5) periodic screens.
When a child has turned five (5) years old, the following schedule will apply. There must be at least 365 days between each screen listed below for children age 5 years through 18 years.
Age
5 years | 10 years | 13 years | 16 years |
6 years | 11 years | 14 years | 17 years |
8 years | 12 years | 15 years | 18 years |
Medical screens for children are required to be performed by the beneficiary's PCP or receive a PCP referral to an authorized Medicaid screening provider. Routine newborn care, vision screens, dental screens and immunizations for childhood diseases do not require PCP referral. See section 262.130 for procedure codes.
Routine newborn care following a vaginal delivery or C-section includes the physical exam of the baby and the conference(s) with newborns parent(s) and is considered to be the initial newborn preventive care screen in the hospital. Newborn screens do not require PCP referral. Certified nurse-midwives may provide newborn screens only. Nurse practitioners may provide newborn screens and are authorized to provide other periodicity related screens with the proper PCP referral.
These may be modified depending upon the entry point into the schedule and the individual need.
These may be modified depending upon the entry point into the schedule and the individual need.
Testing should be done upon recognition of high risk factors.
These may be modified depending upon entry point into schedule and individual need.
Testing should be done upon recognition of high-risk
Developmental, psychosocial and chronic disease issues for children and adolescents may require frequent counseling and treatment visits separate from preventive care visits.
These may be modified, depending upon entry point into schedule and individual need.
Testing should be done upon recognition of high risk factors.
Beneficiaries in the ARKids First-B Program are allowed a monthly benefit of $125.00 for medically necessary medical supplies (see section 222.100 ). Covered medical supplies are listed in Section 262.110 of this manual. In unusual circumstances, when a beneficiary's condition requires additional medical supplies that exceed the monthly benefit, the provider may request extended benefits. To apply for extended benefits for medically necessary medical supplies, Prosthetics and Home Health Providers must refer to and adhere to guidelines detailed in their respective provider manuals.
If the referring PCP or attending physician, in conjunction with the treating speech therapy provider, determines the beneficiary requires additional daily speech therapy services other than those allowed through regular benefits indicated in section 222.600, a request for extended therapy services may be made. The therapist must refer to the guidelines in the Occupational, Physical and Speech Therapy Provider Manual to properly apply for extended benefits.
Screens
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 Human Services Medicaid Dental Unit Address.Refer to your Arkansas Medicaid Dental Services Provider Manual for detailed information on obtaining prior authorizations.
Refer to Section 222.300 of this manual for coverage and section 262.150 billing information.
When an adverse extended services or prior authorization request decision is made, the provider may request an administrative reconsideration and/or the provider and/or the beneficiary may file for a fair hearing or appeal of the denial of services decision as provided is section 190.003 of this manual. The appeal request must be in writing and received by the Appeals and Hearings Section of the Department of Human Services within thirty days of the date on the letter explaining the denial. Appeal requests must be submitted to the Department of Human Services Appeals and Hearings Section. Further details, guidelines and procedures are outlined and provided within the respective discipline's Medicaid Provider Manual. Refer to your individual specialty provider manual for further assistance. View or print the Department of Human Services Appeals and Hearings Section address.
Periodicity schedule once each six months plus one day - must be billed with procedure code D0120.
ARKids B beneficiaries may receive interperiodic preventive dental screening, if required by medical necessity. There are no limits on these services; however, prior authorization must be obtained in order to receive reimbursement. Refer to section 240.200 of this manual for dental prior authorization information.
Procedure code D0140 must be billed for an interperiodic preventive dental screen. This service requires prior authorization (see section 240.200 ).
The procedure codes listed in the table below must be billed for prophylaxis/fluoride.
Procedure Code | Description |
D1110 | Prophylaxis - adult (ages 10-18) |
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 222.300 for further details regarding dental services for ARKids First- B beneficiaries.
ARKids First-B reimburses providers for preventive health screenings performed at the intervals recommended by the American Academy of Pediatrics.
References in this section indicate that ARKids First-B preventive health screenings are similar to Arkansas Medicaid Child Health Services (EPSDT) screens in content and application. However, please note this important distinction:
Claims for ARKids First-B preventive health screenings electronically or by paper must be billed in the CMS-1500 claim format. Do not use the DMS-694 EPSDT claim form nor the restricted EPSDT modifier, EP.
NOTE: Certified nurse-midwives are restricted to performing the preventive health screen, Newborn, only, and must bill either code 99431, 99432 or 99435 for initial newborn screen or codes 99221 or 99223 for newborn illness care.
A Certified nurse-midwife may NOT bill procedure codes 99381-99385 or 99391-99395 for child preventive health screens.
The Vaccines for Children (VFC) Program was established to generate awareness and access for childhood immunizations. These vaccines are available for ARKids First-B beneficiaries who are under the age of 19. To enroll in the VFC Program, contact the Department of Health. Providers may also obtain the vaccines to administer and receive information regarding vaccines covered through the VFC program from the Department of Health. View or print the Department of Health contact information.
Vaccines available through the VFC program are covered for ARKids First-B beneficiaries. Only the administration fee is reimbursed. When filing claims for administering VFC vaccines for ARKids First-B beneficiaries, providers must use the CPT procedure code for the vaccine administered and the required modifier TJ onlyfor either electronic or paper claims. Providers must bill claims for ARKids First-B beneficiaries using the CMS-1500 claim format.
Providers must NOT bill for ARKids First-B beneficiaries on the DMS-694 EPSDT claim form nor use the EPSDT restricted modifier EP.
The following list contains the vaccines available through the VFC program.
Procedure Code | M1 | Age Range | Vaccine Description |
90633 | TJ | 12 months-18 years | Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use |
90634 | TJ | 12 months-18 years | Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for intramuscular use |
90636 | TJ | 18 years only | Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use |
90645 | TJ | 0-18 years | Hemophilus influenza b (Hib) HbOC conjugate (4 dose schedule) for intramuscular use |
90646 | TJ | 0-18 years | Hemophilus influenza b (Hib) PRP-D conjugate for booster use only, intramuscular use |
90647 | TJ | 0-18 years | Hemophilus influenza b (Hib) PRP-OMP conjugate (3 dose schedule), for intramuscular use |
90648 | TJ | 0-18 years | Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use |
90655 | TJ | 6 months-35 months | Influenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use |
90656 | TJ | 3 years-18 years | Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use |
90657 | TJ | 6 months-35 moths | Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use |
90658 | TJ | 3 years-18 years | Influenza virus vaccine, split virus, for use in individuals 3 years and above, for intramuscular use |
90660 | TJ | 2 years-18 years (not pregnant) | Influenza virus vaccine, live, for intranasal use |
90669 | TJ | 0-4 years | Pneumococcal conjugate vaccine polyvalent, for children under 5 years, for intramuscular use |
90680 | TJ | 6 weeks to 32 weeks | Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use |
90700 | TJ | 0-6 years | Diphtheria, tetanus toxoids and acellular pertussis vaccine (DTaP), for use in individuals younger than 7 years, for intramuscular use |
90707 | TJ | 0-18 years | Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use |
90710 | TJ | 0-18 years | Measles, mumps, rubella, and Varicella vaccine (MMRV), live, for subcutaneous use |
90713 | TJ | 0-18 years | Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use |
90714 | TJ | 7-18 years | Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for use in individuals 7 years or older, for intramuscular use |
90715 | TJ | 7-18 years | Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for use in individuals 7 years or older, for intramuscular use |
90716 | TJ | 0-18 years | Varicella virus vaccine, live, for subcutaneous use |
90718 | TJ | 7-18 years | Tetanus and diphtheria toxoids (Td) absorbed for use in individuals 7 years or older, for intramuscular use |
90721 | TJ | 0-18 years | Diphtheria, tetanus toxoids and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use |
90723 | TJ | 0-18 years | Diphtheria, tetanus toxoids and acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine , inactivated (DTaP-HepB-IPV)( for intramuscular use |
90734 | TJ | 0-18 years | Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use |
90743 | TJ | 0-18 years | Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use |
90744 | TJ | 0-18 years | Hepatitis B vaccine, pediatric/adolescent (3 dose schedule), for intramuscular use |
90747 | TJ | 0-18 years | Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use |
90748 | TJ | 0-18 years | Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use |
016.06.09 Ark. Code R. § 004