Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.07-022 - Section V Provider Manual Update Transmittal

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

Claim Type

Where To Get Them

Alternatives Attendant Care Provider Claim Form -AAS-9559

Client Employer

Dental ? ADA-J400

Business Form Supplier

Hospice/INH Claim Form ? DHS-754

EDS ? 1-800-457 -4454

Form Name

Form Number

Acknowledgement of Hysterectomy Information

DMS-2606

Address Change Form

DMS-673

Adjustment Request Form - Medicaid XIX

EDS-AR-004

AFMC Personal Care Assessment and Service Plan for Medicaid Beneficiaries Under Age 21

AFMC-201

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

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

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

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

Personal Care Assessment and Service Plan

DMS-618

Prescription & Prior Authorization Request For Nutrition Therapy & Supplies

DMS-2615

Prescription Drug Prior Authorization and Extension of Benefits Request Form

DMS-2694

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

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

AAS-9502

DMS-2685

DMS-650

AAS-9565

DMS-2687

DMS-651

Address Change

DMS-2692

DMS-652

AFMC-101

DMS-2694

DMS-653

AFMC-102

DMS-2698

DMS-671

AFMC-103

DMS-32-A

DMS-673

AFMC-201

DMS-32-O

DMS-679

AFMC-RBSS

DMS-601

DMS-683

Authorization for

DMS-602

DMS-686

Automatic Deposit

DMS-612

DMS-693

CMS-485

DMS-615

DMS-694 chart version

CSPC-EPSDT

DMS-616

DMS-694 sample

DCO-645

DMS-618

DMS-699

DDS/FS#0001.a

DMS-619

DMS-831

DMS-0663

DMS-628

ECSE-R

DMS-2606

DMS-630

EDS-AR-004

DMS-2608

DMS-632

EDS-CI-003

DMS-2609

DMS-633

EDS-CR-002

DMS-2610

DMS-635

EDS-MFR-001

DMS-2615

DMS-638

MAP-8

DMS-2618

DMS-640

Performance Report

DMS-2633

DMS-646

Provider Enrollment

DMS-2634

Application and Contract

DMS-2635

DMS-647 DMS-648

Package

DMS-2647

DMS-649

PUB-019

PUB-020

Field Name and Number

Instructions for Completion

1. Patient?s Last Name

Enter the patient?s last name.

2. Patient?s First Name

Enter patient?s first name.

3. Patient?s Middle Initial

Enter patient?s middle initial.

4. Patient?s Sex

Check ?M? for male or ?F? for female.

5. Patient?s Medicaid ID No.

Enter the entire 10-digit patient Medicaid identification number.

6. Casehead?s Name

Enter the casehead name for TEA children only. Patient?s name has been requested in Blocks 1, 2 and 3.

7. County of Residence

Enter the patient?s county of residence.

8. Date of Birth

Enter the patient?s date of birth in month and year format as it appears on the Medicaid identification card.

9. Street Address

Enter the patient?s street address.

10. City

Enter the patient?s city of residence.

11. If a Patient is a Referral Enter Name of Referring Physician

Provider Identification Number/Taxonomy Code

If the patient is a referral, enter the name of the referring physician and his or her provider identification number and taxonomy code.

12. Medical Record Number

This is an optional entry that the provider may use for accounting purposes. Enter the patient?s account number, if applicable. Up to 16 numeric or alpha characters will be accepted. This number will appear on the Remittance Advice (RA) and is a method of identifying payment of the claim.

13. Provider Phone Number

Pay To: Provider Name and Address

Pay To: Provider Number

Enter the provider?s complete name, address, provider identification number, and taxonomy code. If a clinic billing is involved, use the clinic provider identification number. Telephone number is requested but not required.

14. Other Health Insurance

Coverage (Enter Name of Plan and Policy Number)

If applicable, enter the name of the insurance plan and the policy number of any health insurance coverage carried by the patient other than Medicaid. The patient?s Medicaid identification card should indicate ?Yes? if other coverage is carried by the beneficiary.

15. Was Condition Related to:

A. Patient?s Employment

Check ?Yes? if the patient?s condition was employment related. If the condition was not employment related, check ?No.?

B. An Accident

Check ?Yes? if the patient?s condition was related to an accident. Check ?No? if the condition was not accident related.

16. Primary Diagnosis or Nature of Injury

Enter the description of the primary reason for treatment of the patient.

Diagnosis Code

Enter the ICD-9-CM Code that identifies the primary diagnosis.

18. Type of Screen Periodic Interperiodic

Not required for Medicaid. Completed by Human Services, if applicable.

SECTION II

20. Examination Report

To be completed by screening provider at time of screen.

A. Basic Screening

Item A, Numbers 1 through 6

Check ?Normal? or ?Abnormal? for each component. Check ?Counseled,? ?Treated? or ?Referred? as applicable.

Item A, Number 7

Give results of the lab tests performed at the time of screen.

Item B

Immunization status appropriate for age and health history. If immunization cannot be performed, note the reason along with the return appointment in ?Comments? section.

Item C

Enter any other services rendered.

21. Comments

Briefly explain any problems identified and describe treatment or referral. If referred, indicate the name of the provider to whom the referral was made.

22. A. Date of Service

Enter the ?from? and ?to? dates of service for each service provided in MM/DD/YY format. A single date of service need not be entered twice on the same line.

B. Place of Service

Enter the appropriate place of service code. See Section 242.200 for codes.

C. Fully Describe Procedures, Medical Services or Supplies Furnished For Each Date Given (Explain Unusual Services or Circumstances)

Enter the appropriate HCPCS, CPT and state assigned procedure code and describe any services or circumstances, e.g., what age periodicity screen has been provided and describe procedures performed (including screen, lab test, immunizations, etc.).

Procedure Code (Identify)

D. Diagnosis Code

Enter the ICD-9-CM code, which corresponds with the procedures performed.

E. Charges

Enter the charges for the rendered services. These charges should be the provider?s current usual and customary fee to private clients.

F. Days or Units

Enter days or units of service rendered.

G. Performing Provider Number

If the billing provider noted in Block 13 is a clinic or group, enter the attending provider?s provider identification number and taxonomy code.

23. Total Charges

Enter the total of Column 22E. This block should contain a sum of charges for all services indicated on the claim form.

24. Covered by Insurance

Enter the total amount of funds received from other sources. The source of payment should be indicated in Block 14. If payment was received from the patient, indicate in Block 14, but DO NOT include the amount in Block 24.

25. Balance Due

Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge.

26. Provider?s Signature

The provider or designated authorized individual must sign the claim certifying that the services were personally rendered by the provider or under the provider?s direction. Provider?s signature? is defined as the provider?s actual signature, a rubber stamp of the provider?s signature, a typewritten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable.

27. Billing Date

Enter date signed.

Field Name and Number

Instructions for Completion

C. Fully Describe Procedures, Medical Services or Supplies Furnished For Each Date Given (Explain Unusual Services or Circumstances)

Enter the appropriate HCPCS, CPT and state assigned procedure code and describe any services or circumstances, e.g., what age periodicity screen has been provided and describe procedures performed (including screen, lab test, immunizations, etc.).

Procedure Code (Identify)

D. Diagnosis Code

Enter the ICD-9-CM code, which corresponds with the procedures performed.

E. Charges

Enter the charges for the rendered services. These charges should be the provider?s current usual and customary fee to private clients.

F. Days or Units

Enter days or units of service rendered.

G. Performing Provider Number

If the billing provider noted in Block 13 is a clinic or group, enter the attending provider?s provider identification number and taxonomy code.

23. Total Charges

Enter the total of Column 22E. This block should contain a sum of charges for all services indicated on the claim form.

24. Covered by Insurance

Enter the total amount of funds received from other sources. The source of payment should be indicated in Block 14. If payment was received from the patient, indicate in Block 14, but DO NOT include the amount in Block 24.

25. Balance Due

Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge.

26. Provider?s Signature

The provider or designated authorized individual must sign the claim certifying that the services were personally rendered by the provider or under the provider?s direction. Provider?s signature? is defined as the provider?s actual signature, a rubber stamp of the provider?s signature, a typewritten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable.

27. Billing Date

Enter date signed.

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, provider identification number and taxonomy code, 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, provider identification number, and taxonomy code.

PROCEDURE CODES:

List all procedure codes (including any modifier(s) 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.

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.