Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.06-080 - ARKids First Provider Manual Update Transmittal #47

Universal Citation: AR Admin Rules 016.06.06-080

Current through Register Vol. 49, No. 9, September, 2024

Section II ARKids First-B

TOC not required

222.300 Dental Services Benefit Limit

Dental services for ARKids First-B participants are limited to one periodic dental exam, bite-wings, and prophylaxis/fluoride treatments every six (6) months plus one (1) day. See section 262.100 to view the procedure code for periodic dental screening exams. Scalings are limited to once per State Fiscal Year (SFY).

The procedure codes listed in the table below may be billed for the prophylaxis/fluoride.

Procedure Code

Description

D1110

Prophylaxis - adult (ages 10-20)

D1120

Prophylaxis - child (ages 0-9)

D1201

Topical application of fluoride (including prophylaxis) - child (ages 0-9)

D1205

Topical application of fluoride (including prophylaxis) - adult (ages 10-18)

Refer to Section II of the Dental Provider Manual for a complete listing of covered dental services. Orthodontia Services are not covered for ARKids First-B participants.

Procedure codes for treatment services that are not shown as payable may be requested on treatment plans subject to review and approval by the Division of Medical Services dental consultants if such treatment is deemed medically necessary.

222.310 Preventive Dental Screens
A. Initial/Periodic Preventive Dental Screens

Procedure code D0120 must be billed for an initial/periodic preventive dental screening.

B. Interperiodic Preventive Dental Screens

ARKids B participants may receive interperiodic preventive dental screening. There is no limit on this service. However, prior authorization must be obtained in order to receive reimbursement. See Section 240.200 for prior authorization information.

Procedure code D0140 must be billed for an interperiodic preventive dental screen. This service requires prior authorization.

240.200 Prior Authorization (PA) Process for Interperiodic Preventive Dental 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 Health and Human Services Medicaid Dental Unit address.

Refer to Section 222.310 of this manual for coverage and billing information.

Section II

ARKids First-B

262.110 Medical Supplies Procedure Codes

The following medical supplies procedure codes may be billed by Medicaid-enrolled Home Health and Prosthetics providers for ARKids First-B participants. Type of service (TOS) codes are used only when billing on paper.

A4206

A4221

A4222

A4253 U1

A4256

A4259 U2

A4265

A4310

A4311

A4312

A4313

A4314

A4315

A4316

A4320

A4322

A4326

A4327

A4328

A4330

A4338

A4340

A4344

A4346

A4348

A4351

A4352

A4354

A4355

A4356

A4357

A4358

A4359

A4361

A4362

A4364

A4367

A4369

A4371

A4397

A4398

A4399

A4400

A4402

A4404

A4405

A4406

A4450

A4452

A4455

A4558

A4561

A4562

A4623

A4624

A4625

A4626

A4628

A4629

A4772

A4927

A5051

A5052

A5053

A5054

A5055

A5061

A5062

A5063

A5071

A5072

A5073

A5081

A5082

A5093

A5102

A5105

A5112

A5113

A5114

A5120

A5121

A5122

A5126

A5131

A6154

A6234

A6241

A6242

A6248

A7520

B4086

E0776

Procedure Code

Required Modifier(s)

TOS Code

Description

A6257

-

Transparent film, each (16 square inches or less)

A6258

-

Transparent film, each (more than 16, but less than 48 square inches)

A6259

-

Transparent film, each (more than 48 square inches)

A6216 A6219 A6228

-

Gauze pads medicated or non-medicated, each (16 square inches or less)

A6217 A6220 A6229

-

Gauze pads medicated or non-medicated, each (more than 16, but less than 48 square inches)

A6403

A6204 A6218 A6221 A6230

-

Gauze pads medicated or non-medicated, each (more than 48 square inches)

A6441 A6446

-

Gauze, non-elastic, per roll (1 linear yard)

A6242 A6245

-

Hydrogel dressing, each (16 square inches or less)

A6243 A6246

-

Hydrogel dressing, each (more than 16, but less than 48 square inches)

A6244 A6247

-

Hydrogel dressing, each (more than 48 square inches)

A6248

-

Hydrogel dressing, each (1 ounce)

A6234 A6237

-

Hydrocolloid dressing, each (16 square inches or less)

A6235 A6238

-

Hydrocolloid dressing, each (more than 16, but less than 48 square inches)

A6238

U1

Hydrocolloid dressing, each (more than 48 square inches)

A6196

-

Alginate dressing, each (16 square inches or less)

A6197

-

Alginate dressing, each (more than 16, but less than 48 square inches)

A6198

-

Alginate dressing, each (more than 48 square inches)

A6197

-

Alginate dressing, each (1 linear yard)

A6209 A6212

-

Foam dressing, each (16 square inches or less)

A6210 A6213

-

Foam dressing, each (more than 16, but less than 48 square inches)

A6211

-

Foam dressing, each (more than 48 square inches)

A6200 A6203

-

Composite dressing, each (16 square inches or less)

A6201 A6204

-

Composite dressing, each (more than 16, but less than 48 square inches)

A6202 A6205

-

Composite dressing, each (more than 48 square inches)

A4253

-

Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

A4353

-

Urinary intermittent catheter with insertion supplies

A4394

-

Ostomy deodorant, all types, per ounce

A4365

-

Adhesive remover wipes, any type, per 50

A4368

-

Ostomy filters, any type, each

A6449 A6452

-

Gauze elastic, all types, per roll (linear yard)

A4483

-

Moisture exchange/agreer, disposable, for use with invasive mech

B4100

-

H

Food thickener, administered orally, per oz.

A6549*

-

Stocking (Jobst)

*NOTE: A4221, A4222 and A6549 must be prior authorized. Form AFMC-103 must be used for the request for prior authorization. View or print form AFMC-103 and instructions for completion.

The costs of B4100 and A6549 are not subject to the $125 medical supplies monthly benefit limit.

The following procedure code must be utilized when billing for Pedia-Pop. Reimbursement for this product is provider's cost plus ten percent. Pedia-Pop is only for oral consumption, and only in frozen form.

Z2487 Pedia-Pop 1 unit = 1 box Maximum = 2 units per date of service

NOTE: Pedia-Pop must be billed on paper.

Disclaimer: These regulations may not be the most recent version. Arkansas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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