Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.06-081 - Section V Update - All Providers and Prosthetics Update #90
Current through Register Vol. 49, No. 9, September, 2024
Section II Prosthetics
The following conditions must be met for the provision of services:
A beneficiary's place of residence for services may not include a hospital, skilled nursing facility, intermediate care facility or any other supervised living situation that is required to provide prosthetics services under a provider agreement or contract as required by federal, state or local regulation.
At least once every 6 months, the primary care physician must certify the medical necessity for services and prescribe them by signing and dating a prescription. When applicable, the primary care physician must complete a prior authorization form; either a Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) when prescribing services for wheelchairs and wheelchair seating systems, or wheelchair repairs or a form AFMC-103, titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components when prescribing orthotic appliances, prosthetic devices or durable medical equipment. View or print form DMS-679 and instructions for completion. View or print form AFMC-103 and instructions for completion.
At least once every 6 months, the prosthetics provider must receive a prescription for prosthetics services from the beneficiary's primary care physician and, when applicable:
As necessary, the provider must:
At least once every 6 months, but within 30 working days before the end of currently prescribed or prior authorized prosthetics services, the prosthetics provider must obtain a new prescription from the beneficiary's primary care physician and, if applicable, send a new prior authorization form to the applicable entity. The primary care physician must initially review either form DMS-679 or form AFMC-103, and, based upon the physician's certification of medical necessity, prescribe services. Form DMS-679 or form AFMC-103 must then be reviewed by the applicable entity and services must be prior authorized. If services are prescribed, and when applicable, prior authorized, services may be furnished for a maximum of 6 months from the date of the prescription.
Form DMS-699, titled Request for Extension of Benefits, serves as both a request form and a notification of approval or denial of extension of benefits when requesting diapers and underpads for beneficiaries age 3 and older. If the benefit extension is approved, the form returned to the provider will contain a Benefit Extension Control Number. The approval notification will also list the procedure codes approved for benefit extension, the approved dates or date-of-service range and the number of units of service (or dollars, when applicable) authorized.
Upon notification of a benefit extension approval, providers may file the benefit extension claims electronically, entering the assigned Benefit Extension Control Number in the Prior Authorization (PA) number field. Subsequent benefit extension requests to the Utilization Review Section will be necessary only when the Benefit Extension Control Number expires or when a beneficiary's need for services unexpectedly exceeds the amount or number of services granted under the benefit extension.
Form AFMC-103, titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components serves as a request form when requesting extension of benefits for the augmentative communication device. AFMC will notify providers of approval or denial by letter.
Arkansas Medicaid covers apnea monitors only for infants less than one (1) year of age. Use of the apnea monitor must be medically necessary and prescribed by a physician.
A primary care physician (PCP) is not required until an infant's Medicaid eligibility has been determined. No PCP referral for medical services is required for retroactive eligibility periods.
Prior authorization is not required for the initial one-month period of use of the monitor. If the apnea monitor is needed longer than an initial one-month period, prior authorization will be required.
Prior authorization of the apnea monitor is required after an infant has been monitored for one month. A new referral and prescription is required. Compliance during the initial thirty-day period and proof of medical necessity for the continuation of monitoring must be documented.
After the initial thirty-day period, the prescribing physician must sign form AFMC-103, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. The physician's signature must be an original, not a stamp. When an apnea monitor is prescribed during a hospital discharge, the physician ordering the apnea monitor must be a neonatologist or pulmonologist.
As necessary, the PCP's name and provider number must also be indicated on form AFMC-103. The PCP's signature is not required on the initial certification but he or she must sign all re-certifications.
Documentation from the physician describing the education of the family regarding their understanding of the importance of the apnea monitor must be included after the initial one-month period.
The following criteria, which follow the guidelines set by the National Institute of Health Consensus Statement on Infantile Apnea on Home Monitoring, Consensus Development Conference Statement, September 29-October 1, 1986, will be utilized in evaluating the need for an apnea monitor after the initial one-month period:
Prior authorization for the apnea monitor must be submitted to AFMC on form AFMC-103, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print form AFMC-103 and instructions for completion. View or print AFMC contact information.
The augmentative communication device (ACD) is covered for beneficiaries of all ages. Coverage for beneficiaries under 21 years of age must result from an EPSDT screen. There is a $7,500.00 lifetime benefit for augmentative communication devices. When a beneficiary who is under age 21 has met the lifetime benefit and it is determined that additional equipment is medically necessary, the provider may request an extension of benefits by submitting form AFMC-103. View or print form AFMC-103.
The ACD is also covered for Medicaid beneficiaries 21 years old and older. Prior authorization is required on the device and on repairs of the device. For beneficiaries who are age 21 and above, there is a $7,500.00 lifetime benefit without benefit extensions.
The Arkansas Medicaid Program will not cover ACDs that are prescribed solely for social or educational development.
Training in the use of the device is not included and is not a covered cost.
Prior authorization must be requested for repairs of equipment or associated items after the expiration of the initial maintenance agreement.
The following information must be submitted when requesting prior authorization for ACDs for Medicaid beneficiaries.
Submit form AFMC-103, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print form AFMC-103 and instructions for completion. The form should be accompanied by:
This information must be submitted to AFMC. View or print AFMC contact information.
Benefit Limit
There is a $7500 lifetime benefit for augmentative communication devices. When the beneficiary under age 21 has met the limit and it is determined that additional equipment is necessary, the provider may request an extension of benefits.
In order to obtain an extension of the $7,500.00 lifetime benefit for beneficiaries under 21 years of age, a medical necessity determination for additional equipment is required. The provider must submit a form AFMC-103, a completed Medicaid claim and medical records substantiating medical necessity that the beneficiary cannot function using his or her existing equipment and whether the equipment can be repaired or needs repair. The information must be sent to AFMC. View or print form AFMC-103, titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print the AFMC contact information.
The provider will be notified in writing of the approval or denial of the request for extended benefits.
Arkansas Medicaid covers the automatic electronic blood pressure monitor for beneficiaries of all ages as a rental-only item. A provider must substantiate that an accurate blood pressure reading cannot be obtained by using a regular blood pressure monitor. Providers must also supply one disposable blood pressure cuff each month.
Prior authorization is required for the use of this item. Providers may request prior authorization by submitting form AFMC-103, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC. View or print form AFMC-103 and instructions for completion. View or print AFMC contact information.
The request for an enteral nutrition pump is covered on a case-by-case basis for beneficiaries under age 21 who require supplemental feeding because of medical necessity. Sufficient medical documentation must be provided to establish that the enteral nutrition infusion pump is medically necessary (e.g., supplemental feeding must be given over an extended period of time due to reflux, cystic fibrosis, etc.). The PCP or appropriate physician specialist must prescribe the pump, citing the medical reason that bolus feeds are inappropriate.
Reimbursement for use in the home may be made for the pump supply kit when the feeding method involves an enteral nutrition infusion pump. The pump supply kit and the infusion pump require prior authorization from AFMC using form AFMC-103, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print AFMC contact information. View or print form AFMC-103 and instructions for completion.
The enteral feeding pump supply kit, necessary for the administration of the nutrients when the feeding method involves an enteral nutrition infusion pump, is reimbursed on a per-unit basis with 1 day equaling 1 unit of service. A maximum of 1 unit per day is allowed. The pump supply kit includes pump sets, containers and syringes necessary for administration of the nutrients.
Reimbursement for the enteral nutrition infusion pump is based on a rent-to-purchase methodology. Each unit reimbursed by Medicaid will apply towards the purchase price established by Medicaid. Reimbursement will only be approved for new equipment. Used equipment will not be prior authorized. View or print form AFMC-103 and instructions for completion.
Requests for prior authorization for enteral pump repairs must be mailed to AFMC. Form AFMC-103, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be used to request prior authorization. View or print form AFMC-103 and instructions for completion.
Insulin pumps and supplies are covered by Arkansas Medicaid for beneficiaries of all ages.
Prior authorization is required for the insulin pump. A prescription and proof of medical necessity are required. The patient must be educated on the use of the pump, but the education is not a covered service.
Insulin is also not covered because it is covered in the prescription drug program.
The following criteria will be utilized in evaluating the need for the insulin pump:
Prior authorization requests for the insulin pump and supplies must be submitted on form AFMC-103, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, to AFMC. View or print form AFMC-103 and instructions for completion. View or print AFMC contact information.
and Supplies for Beneficiaries Under Age 21
The Arkansas Medicaid Program reimburses for the MIC-KEY Skin Level Gastrostomy Tube (Mic-Key button) and supplies for Medicaid-eligible beneficiaries under age 21. Prior authorization (PA) from AFMC is required.
The procedure codes may also be authorized for Medicaid-eligible children ages 0 through 5 years who receive their sole-source enteral formula through the Women, Infants and Children (WIC) Program. AFMC must be contacted to receive the prior authorization.
When requesting prior authorization, form AFMC-103, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be completed and sent, along with sufficient medical documentation, to AFMC.
The MIC-KEY Kit is benefit limited to 2 per state fiscal year (SFY). The accessories, extension sets and adapters are covered under the $250 medical supply benefit limit.
Benefit extensions will be considered on a case-by-case basis if proven to be medically necessary. Prior authorization must be obtained from AFMC for any extensions using form AFMC-103. View or print AFMC contact information. View or print form AFMC-103 and instructions for completion.
Arkansas Medicaid covers specialized rehabilitative equipment for Medicaid-eligible beneficiaries of all ages.
Some items of specialized equipment require prior authorization from AFMC. View or print form AFMC-103 and instructions for completion. View or print AFMC contact information.
The following restrictions apply to the coverage of orthotic appliances for beneficiaries age 21 and over:
The appropriate forms (or the required information in a different format) must accompany the form AFMC-103. View or print AFMC-103, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components and instructions for completion.
The forms and their titles are as follows:
|
1. DMS-646 |
Evaluation Form Lower Limb. View or print form DMS-646. |
|
2. DMS-647 |
Gait Analysis: Full Body. View or print form DMS-647. |
|
3. DMS-648 |
Prosthetic-Orthotic Upper-Limb Amputee Evaluation. View or print form DMS-648. |
|
4. DMS-649 |
Upper-Limb Prosthetic Prescription. View or print form DMS-649. |
|
5. DMS-650 |
Prosthetic-Orthotic Lower-Limb Amputee Evaluation. View or print form DMS-650. |
|
6. DMS-651 |
Lower-Limb Prosthetic Prescription. View or print form DMS-651 |
A prescription for oxygen must be accompanied by a current arterial blood gas (ABG) laboratory report from a certified laboratory or the patient's attending physician. A current laboratory report is defined as one performed within a maximum of 30 days prior to the prescription for oxygen.
A prescription for oxygen must specify the oxygen flow rate, frequency and duration of use, estimate of the period of need for oxygen and method of delivery of oxygen to the patient (e.g., two liters per minute, 10 minutes per hour, by nasal cannula for a period of two months). A prescription containing only "oxygen PRN" is not sufficient.
The following medical criteria will be utilized in evaluating coverage of oxygen:
Pa02 with exercise less than 55 mm Hg
Symptomatic at rest, with Pa02 less than 60 mm Hg
Resting Pa02 less than 60 mm Hg
Reviewed on an individual basis
The prior authorization request for all oxygen and respiratory equipment must be submitted on form AFMC-103, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC for beneficiaries of all ages. View or print form AFMC-103 and instructions for completion.
Reimbursement for specified prosthetics services must be prior authorized. Prior authorization is required on items indicated (e.g., oxygen) or if the reimbursement for an item or items is $1000.00 or more (e.g., wheelchair and/or components).
The request for prior authorization must originate with the prosthetics provider. The provider is responsible for obtaining the required medical information and prescription needed for completion of the prior authorization request form.
The Medical Equipment Request for Prior Authorization and Prescription Form (Form DMS-679) must contain a diagnosis of the disease(s) necessitating use of prosthetics services. View or print form DMS-679 and instructions for completion.
Requests for prior authorization will be handled by either Utilization Review with the Division of Medical Services or by the Arkansas Foundation for Medical Care, depending on the service field that is being requested.
For denied cases, both Utilization Review and AFMC will mail a letter containing case specific rationale that explains why the request was not approved to the requesting provider and to the Medicaid beneficiary within 30 working days of receipt of the prior authorization request.
The provider may request reconsideration of the denial within thirty-five calendar days of the denial date. Requests must be made in writing and include additional documentation to substantiate the medical necessity of the requested services. Requests received after thirty-five calendar days of the denial date will not be accepted for reconsideration.
If the denial decision is reversed during the reconsideration review, an approval is forwarded to the provider specifying the approved units and services. If the denial decision is upheld, the provider and the Medicaid beneficiary will be notified in writing of the review determination.
Reconsideration is available only once per prior authorization request. However, if the denial is upheld during the reconsideration process, the provider may submit a new prior authorization request, for different dates of service, providing new supporting documentation is available. A subsequent prior authorization request will not be reviewed if it contains the same documentation submitted with the previous authorization and reconsideration requests.
The Medicaid beneficiary may request a fair hearing of a denied review determination made by either Utilization Review, Department of Health and Human Services (DHHS) or the Arkansas Foundation for Medical Care (AFMC). The fair hearing request must be in writing and sent to the Appeals and Hearings Section of DHHS within thirty-five calendar days of the date on the denial letter. View or print the Department of Health and Human Services Appeals and Hearings Section contact information. Providers may refer to section 190.000 for information regarding provider appeals through the Medicaid Fairness Act.
Reimbursement for repairs to the enteral nutrition infusion pump requires prior authorization. Repairs will be approved only on equipment purchased by Medicaid. Therefore, no repairs will be reimbursable prior to the equipment becoming the property of the Medicaid beneficiary.
Requests for prior authorization for enteral pump repairs must be mailed to AFMC. (View or print AFMC contact information) on form AFMC-103, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. (View or print form AFMC-103 and instructions for completion.)
The repair invoice and the serial number of the equipment must accompany the prior authorization request form. Total repair costs to an infusion pump may not exceed $290.93. Medicaid will not reimburse for additional repairs to an infusion pump after the provider has billed repair invoices totaling $290.93. If the equipment is still not in proper working order after the provider has billed the Medicaid maximum allowed for repairs, the provider must supply the beneficiary with a new infusion pump and may bill either procedure code B9000 or B9002 after receiving prior authorization for the new piece of equipment.
Procedure codes found in this section must be billed either electronically or on paper with modifier NU for individuals of all ages. When a second modifier is listed, that modifier must be used in conjunction with the modifier NU.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "H" for individuals of all ages.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.
Medical Supplies, All Ages (section 242.120)
|
Procedure Code |
M1 M2 |
TOS |
Description |
||
|
A4206 |
NU |
H |
Syringe with needle, sterile, 1 cc, ea |
||
|
A4207 |
NU |
Syringe with needle, sterile, 2 cc, ea |
|||
|
A4209 |
NU |
Syringe with needle, sterile, 5 cc or greater, ea |
|||
|
A4216 |
NU |
H |
Sterile water/saline, 10 ml |
||
|
A4217 |
NU |
H |
Sterile water/saline, 500 ml |
||
|
A42211 |
NU |
Supplies for maintenance of drug infusion catheter, per week (list drug separately) |
|||
|
A42221 |
NU |
Supplies for external drug infusion pump, per cassette or bag (list drug separately) |
|||
|
A4253 |
NU |
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
|||
|
A4253 |
NU UB |
H |
Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |
||
|
A4256 |
NU |
Normal, low, and high calibrator solution/chips |
|||
|
A4259 |
NU |
Lancets, per box of 100 |
|||
|
A4265 |
NU |
Paraffin, per pound |
|||
|
A4310 |
NU |
Insertion tray without drainage bag and without catheter (accessories only) |
|||
|
A4311 |
NU |
Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.) |
|||
|
A4312 |
NU |
Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone |
|||
|
A4313 |
NU |
Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation |
|||
|
A4314 |
NU |
Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc. |
|||
|
A4315 |
NU |
Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all silicone |
|||
|
A4316 |
NU |
Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation |
|||
|
A4320 |
NU |
Irrigation tray with bulb or piston syringe, any purpose |
|||
|
A4322 |
NU |
Irrigation syringe, bulb or piston, each |
|||
|
A4326 |
NU |
Male external catheter specialty type with intergral collection chamber, each |
|||
|
A4327 |
NU |
Female external urinary collection device; metal cup, each |
|||
|
A4328 |
NU |
Female external urinary collection device; pouch, each |
|||
|
A4330 |
NU |
Perianal fecal collection pouch with adhesive, each |
|||
|
A4331 |
NU |
Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each |
|||
|
A4338 |
NU |
Indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc), each |
|||
|
A4340 |
NU |
Indwelling catheter; specialty type (e.g., coude, mushroom, wing, etc.), each |
|||
|
A4344 |
NU |
Indwelling catheter, Foley type, two-way, all silicone, each |
|||
|
A4346 |
NU |
Indwelling catheter, Foley type, three-way for continuous irrigation, each |
|||
|
A4348 |
NU |
Male external catheter with integral collection compartment, extended wear, each (e.g., 2 per month) |
|||
|
A4349 |
NU |
Male external catheter with or without adhesive, disposable, each |
|||
|
A4351 |
NU |
Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), each |
|||
|
A4351 |
NU |
U1 |
Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), each |
||
|
A4352 |
NU |
Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric or hydrophilic, etc.), each |
|||
|
A4352 |
NU |
U1 |
Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric or hydrophilic, etc.), each |
||
|
A4353 |
NU |
U2 |
H |
Intermittent urinary catheter, with insertion supplies (tray) |
|
|
A4354 |
NU |
Insertion tray with drainage bag but without catheter |
|||
|
A4355 |
NU |
Irrigation tubing set for continuous bladder irrigation through a three-way indwelling Foley catheter, each |
|||
|
A4356 |
NU |
External urethral clamp or compression device (not to be used for catheter clamp), each |
|||
|
A4357 |
NU |
Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each |
|||
|
A4358 |
NU |
Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each |
|||
|
A4359 |
NU |
Urinary suspensory without leg bag, each |
|||
|
A4361 |
NU |
Ostomy faceplate, each |
|||
|
A4362 |
NU |
Skin barrier; solid, four by four or equivalent; each |
|||
|
A4364 |
NU |
Adhesive, liquid, or equal, any type, per ounce |
|||
|
A4365 |
NU |
H |
Adhesive remover wipes, any type, per 50 |
||
|
A4367 |
NU |
Ostomy belt, each |
|||
|
A4368 |
NU |
H |
Ostomy filter, any type, each |
||
|
A4369 |
NU |
Ostomy skin barrier, liquid, (spray, brush, etc), peroz |
|||
|
A4371 |
NU |
Ostomy skin barrier, power, per oz |
|||
|
A4394 |
NU |
H |
Ostomy deodorant for use in ostomy pouch, liquid, per fluid ounce |
||
|
A4397 |
NU |
Irrigation supply; sleeve, each |
|||
|
A4398 |
NU |
Ostomy irrigation supply; bag, each |
|||
|
A4399 |
NU |
Ostomy irrigation supply; cone/catheter, including brush |
|||
|
A4400 |
NU |
Ostomy irrigation set |
|||
|
A4402 |
NU |
Lubricant, per ounce |
|||
|
A4404 |
NU |
Ostomy ring, each |
|||
|
A4405 |
NU |
Ostomy skin barrier, non-pectin based, paste, per ounce |
|||
|
A4406 |
NU |
Ostomy skin barrier, pectin based, paste, per ounce |
|||
|
A4414 |
NU |
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4x4 inches or smaller, each |
|||
|
A4450 |
NU |
U1 |
Tape, non-waterproof, per 18 square inches |
||
|
A4450 |
NU |
H |
Tape, non-waterproof, per 18 square inches |
||
|
A4452 |
NU |
Tape, waterproof, per 18 square inches |
|||
|
A4455 |
NU |
Adhesive remover or solvent (for tape, cement or other adhesive), per ounce |
|||
|
A4483 |
NU |
H |
Moisture exchanger, disposable, for use with invasive mechanical ventilation |
||
|
A4558 |
NU |
Conductive paste or gel |
|||
|
A4561 |
NU |
U1 |
Pessary, rubber, any type |
||
|
A4562 |
NU |
Pessary, non rubber, any type |
|||
|
A4623 |
NU |
Tracheostomy, inner cannula |
|||
|
A4625 |
NU |
Tracheostomy care kit for new tracheostomy |
|||
|
A4626 |
NU |
Tracheostomy cleaning brush, each |
|||
|
A4628 |
NU |
Oropharyngeal suction catheter, each |
|||
|
A4629 |
NU |
Tracheostomy care kit for established tracheostomy |
|||
|
A4772 |
NU |
Blood glucose test strips, for dialysis, per 50 |
|||
|
A4927 |
NU |
Gloves, non-sterile, per 100 |
|||
|
A5051 |
NU |
Ostomy pouch, closed; with barrier attached (one piece), each |
|||
|
A5052 |
NU |
Ostomy pouch, closed; without barrier attached (one piece), each |
|||
|
A5053 |
NU |
Ostomy pouch, closed; for use on faceplate, each |
|||
|
A5054 |
NU |
Ostomy pouch, closed; for use on barrier with flange (two piece), each |
|||
|
A5055 |
NU |
Stoma cap |
|||
|
A5061 |
NU |
U1 |
Ostomy pouch, drainable; with barrier attached (one piece), each |
||
|
A5062 |
NU |
Ostomy pouch, drainable; without barrier attached (one piece), each |
|||
|
A5063 |
NU |
Ostomy pouch, drainable; for use on barrier with flange (two piece system), each |
|||
|
A5071 |
NU |
Ostomy pouch, urinary; with barrier attached (one piece), each |
|||
|
A5072 |
NU |
Ostomy pouch, urinary; without barrier attached (one piece), each |
|||
|
A5073 |
NU |
Ostomy pouch, urinary; for use on barrier with flange (two piece), each |
|||
|
A5081 |
NU |
Continent device; plug for continent stoma |
|||
|
A5082 |
NU |
Continent device; catheter for continent stoma |
|||
|
A5093 |
NU |
Ostomy accessory; convex insert |
|||
|
A5102 |
NU |
Bedside drainage bottle, with or without tubing, rigid or expandable, each |
|||
|
A5105 |
NU |
Urinary suspensory; with leg bag, with or without tube |
|||
|
A5112 |
NU |
Urinary leg bag; latex |
|||
|
A5113 |
NU |
Leg strap; latex, replacement only, per set |
|||
|
A5114 |
NU |
Leg strap; foam or fabric, replacement only, per set |
|||
|
A5119 |
NU |
Skin barrier; wipes, box per 50 |
|||
|
A5121 |
NU |
Skin barrier; solid, 6 x 6 or equivalent, each |
|||
|
A5122 |
NU |
Skin barrier; solid, 8 x 8 or equivalent, each |
|||
|
A5126 |
NU |
Adhesive or non-adhesive; disk or foam pad |
|||
|
A5131 |
NU |
Appliance cleaner, incontinence and ostomy appliances, per 16 oz. |
|||
|
A6154 |
NU |
Wound pouch, each |
|||
|
A6196 |
NU |
H |
Alginate or other fiber gelling dressing, wound cover, pad size 16 sq. in. or less, each dressing |
||
|
A6197 |
NU U |
B H |
Alginate or other fiber gelling dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in, each dressing |
||
|
A6197 |
NU U |
B H |
Alginate or other fiber gelling dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in, each dressing (1 linear yard) |
||
|
A6198 |
NU |
H |
Alginate or other fiber gelling dressing, wound cover, pad size more than 48 sq. in., each dressing |
||
|
A6203 |
NU |
H |
Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing |
||
|
A6204 |
NU |
H |
Composite dressing, pad size more than 16 sq. in. but less than 48 sq. in., with any size adhesive border, each dressing |
||
|
A6205 |
NU |
H |
Composite dressing, pad size more than 48 sq. in., with any size adhesive border, each dressing |
||
|
A6211 |
NU |
H |
Foam dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing |
||
|
A6212 |
NU |
H |
Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing |
||
|
A6213 |
NU |
H |
Foam dressing, wound cover, pad size more than 16 sq. in but less than or equal to 48 sq. in., with any size adhesive border, each dressing |
||
|
A6216 |
NU |
H |
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
||
|
A6219 |
NU |
H |
Gauze, non-impregnated, 16 sq. in. or less with any size adhesive border, each dressing |
||
|
A6220 |
NU |
H |
Gauze, non-impregnated, pad more than 16 sq. in., but less than or equal to 48 sq. in., with any size adhesive border, each dressing |
||
|
A6221 |
NU |
H |
Gauze, non-impregnated, pad size more than 48 sq. in., with any size adhesive border, each dressing |
||
|
A6228 |
NU |
H |
Gauze, impregnated, water or normal saline, pad, size 16 sq. in. or less, without adhesive border, each dressing |
||
|
A6229 |
NU |
H |
Gauze, impregnated, water or normal saline, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing |
||
|
A6230 |
NU |
H |
Gauze, impregnated, water or normal saline, pad more than 48 sq. in., without adhesive border, each dressing |
||
|
A6234 |
NU |
U1 |
Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing |
||
|
A6234 |
NU |
H |
Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing |
||
|
A6235 |
NU |
H |
Hydrocolloid dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing |
||
|
A6236 |
NU |
H |
Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing |
||
|
A6237 |
NU |
H |
Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing |
||
|
A6238 |
NU |
H |
Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing |
||
|
A6238 |
NU |
U1 |
H |
Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing |
|
|
A6239 |
NU |
H |
Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing |
||
|
A6241 |
NU |
Hydrocolloid dressing, wound filler, dry form, per gram |
|||
|
A6242 |
NU |
Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing |
|||
|
A6242 |
NU |
U1 |
Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing |
||
|
A6242 |
NU |
H |
Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing |
||
|
A6243 |
NU |
H |
Hydrogel dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing |
||
|
A6244 |
NU |
H |
Hydrogel dressing, wound cover, pad size more than 48 sq. in. without adhesive border, each dressing |
||
|
A6245 |
NU |
H |
Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing |
||
|
A6246 |
NU |
H |
Hydrogel dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., with any size adhesive border, each dressing |
||
|
A6247 |
NU |
H |
Hydrogel dressing, wound cover, pad size more than 48 sq. in. with any size adhesive border, each dressing |
||
|
A6248 |
NU |
Hydrogel dressing, wound filler, gel, per fluid ounce |
|||
|
A6248 |
NU |
U1 |
Hydrogel dressing, wound filler, gel, per fluid ounce |
||
|
A6248 |
NU |
H |
Hydrogel dressing, wound filler, gel, per fluid ounce |
||
|
A6257 |
NU |
H |
Transparent film, 16 sq. in. or less, each dressing |
||
|
A6258 |
NU |
H |
Transparent film, more than 16 sq. in., but less than or equal to 48 sq. in., each dressing |
||
|
A6259 |
NU |
H |
Transparent film, more than 48 sq. in., each dressing |
||
|
A6403 |
NU |
H |
Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than 48 sq. in., without adhesive border, each dressing |
||
|
A6404 |
NU |
H |
Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing |
||
|
A6441 |
NU |
H |
Padding bandage, non-elastic, non-woven/non-knitted, width [GREATER THAN] or = 3 inches & [LESS THAN] 5 in, per yd |
||
|
A6442 |
NU |
Conforming bandage, non-elastic, knitted/woven, non-sterile, width [LESS THAN] 3 in, per yd |
|||
|
A6443 |
NU |
H |
Conforming bandage, non-elastic, knitted/woven, non-sterile, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd |
||
|
A6444 |
NU |
H |
Conforming bandage, non-elastic, knitted/woven, non-sterile, width [GREATER THAN] or= 5 in, per yd |
||
|
A6445 |
NU |
Conforming bandage, non-elastic, knitted/woven sterile, width [LESS THAN]3 in, per yd |
|||
|
A6446 |
NU |
H |
Conforming bandage, non-elastic, knitted/woven, sterile, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd |
||
|
A6447 |
NU |
H |
Conforming bandage, non-elastic, knitted/woven, sterile, width [GREATER THAN] or= 5 in, per yd |
||
|
A6448 |
NU |
Light compression bandage, elastic, knitted/woven width[LESS THAN]3in, per yd |
|||
|
A6449 |
NU |
H |
Light compression bandage, elastic, knitted/woven, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd |
||
|
A6450 |
NU |
H |
Light compression bandage, elastic, knitted/woven, width [GREATER THAN] or = 5 in, per yd |
||
|
A6451 |
NU |
H |
Moderate compress bandage, elastic, knitted/woven load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd |
||
|
A6452 |
NU |
H |
High compress bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50 % maximum stretch, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd |
||
|
A6453 |
NU |
Self-adherent bandage, elastic, non-knitted/non-woven, width[LESS THAN]3in, per yd |
|||
|
A6454 |
NU |
Self-adherent bandage, elastic, non-knitted/non-woven, width [GREATER THAN] or = 3 in & [LESS THAN] 5 in, per yd |
|||
|
A6455 |
NU |
Self-adherent bandage, elastic, non-knitted/non-woven, width [GREATER THAN] or= 5 in, per yd |
|||
|
A65011 |
NU |
Compression burn garment, body suit (head to foot), custom fabricated |
|||
|
A65021 |
NU |
Compression burn garment, chin strap, custom fabricated |
|||
|
A65031 |
NU |
Compression burn garment, facial hood, custom fabricated |
|||
|
A65041 |
NU |
Compression burn garment, glove to wrist, custom fabricated |
|||
|
A65051 |
NU |
Compression burn garment, glove to elbow, custom fabricated |
|||
|
A65061 |
NU |
Compression burn garment, glove to axilla, custom fabricated |
|||
|
A65071 |
NU |
Compression burn garment, foot to knee length, custom fabricated |
|||
|
A65081 |
NU |
Compression burn garment, foot to thigh length, custom fabricated |
|||
|
A65091 |
NU |
Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated |
|||
|
A65101 |
NU |
Compression burn garment, trunk including arms down to leg openings (leotard), custom fabricated |
|||
|
A65111 |
NU |
Compression burn garment, lower trunk including leg openings (panty), custom fabricated |
|||
|
A65121 |
NU |
Compression burn garment, not otherwise classified |
|||
|
A7520 |
NU |
Trachestomy/Laryngectomy tube, non-cuffed, PVC, silicone or equal, each |
|||
|
A7521 |
Trachestoomy/Laryngectomy tube, cuffed, PVC, silicone or equal, each |
||||
|
A7522 |
Trachestomy/Laryngectomy tube, stainless steel or equal, (sterilizable and reusable), each |
||||
|
A7524 |
PO-Tracheostoma stent/stud/button, each |
||||
|
A7525 |
Tracheostomy mask, each |
||||
|
B4086 |
NU |
Gastrostomy/jejunostomy tube, any material, any type, (standard or low profile), each |
|||
|
E0776 |
NU |
IV pole |
|||
The gradient compression stocking (Jobst) is payable for individuals of all ages. However, before supplying the item, the Jobst stocking must be prior authorized by AFMC. View or print form AFMC-103 and instructions for completion. Documentation accompanying form AFMC-103 must indicate that the patient has severe varicose veins with edema, or a venous statis ulcer, unresponsive to conventional therapy such as wrappings, over-the-counter stockings and Unna boots. The documentation must include clinical medical records from a physician detailing the failure of conventional therapy.
|
A6549 |
NU |
H |
Gradient compression stocking, NOS (Jobst); 1 unit = 1 stocking |
Maximum 4 units per date of service |
Kit
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age. When a second modifier is listed, that modifier must be used in conjunction with EP.
Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "6" for beneficiaries under age 21.
The procedure codes will require prior authorization from AFMC.
Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a "Y" in the column; if not, an "N" is shown.
***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.
|
Procedure Code |
M1 |
M2 |
TOS |
Description |
Maximum Units |
PA |
Payment Method |
|
B4035 |
EP |
6 |
Enteral feeding supply kit, pump fed, per day (1 unit = 1 day) |
1 per day |
Y |
Purchase |
|
|
B9000 |
EP |
6 |
Enteral nutrition infusion pump - without alarm (1 day = 1 unit) |
1 per day |
Y |
Rent to Purchase |
|
|
B9002 |
EP |
6 |
Enteral nutrition infusion pump-with alarm (1 day = 1 unit) |
1 per day |
Y |
Rent to Purchase |
|
|
E1340 |
EP |
U2 |
6 |
***(Repair- Enteral nutrition infusion pump) Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component |
Y |
Enteral Nutrition Infusion Pump
Reimbursement for the enteral nutrition infusion pump is based on a rent-to-purchase methodology. Each unit reimbursed by Medicaid will apply towards the purchase price established by Medicaid. Reimbursement will only be approved for new equipment. Used equipment will not be prior authorized. Procedure codes B9000 and B9002 represent a new piece of equipment being reimbursed by Medicaid on the rent-to-purchase plan. Codes B9000 and B9002 are reimbursed on a per unit basis with 1 day equaling 1 unit of service per day. Medicaid will reimburse on the rent-to-purchase plan for a total of 304 units of service. After reimbursement has been made for 304 units, the equipment will become the property of the
Medicaid beneficiary. Prior authorization is required for codes B9000 and B9002. The prior authorization request must include the serial number of the infusion pump being provided to the beneficiary.
See section 236.000 for reimbursement when the Medicaid Program is billed for repairs made to the enteral infusion pump.
Arkansas Foundation for Medical Care Contact Information:
|
In-state and Out-of-state Toll Free: |
1-877-650-2362 |
|
Fort Smith Exchange: |
(479) 649- 8501 |
|
Fax Number: |
(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 |
Instructions 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, assigned nine-(9) digit Arkansas Medicaid provider number 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 and assigned nine-(9) digit Arkansas Medicaid provider number. |
|
PROCEDURE CODES: |
List all procedure codes (including any modifier or type of service if applicable) 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. |
