Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.08-032 - Section V Provider Manual Update Transmittal

Universal Citation: AR Admin Rules 016.06.08-032

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

Section V

Claim Forms

Red-inkClaim Forms

The following is a list of the red-ink claim forms required by Arkansas Medicaid. The forms below cannot be printed from this manual for use. Information about where to get the forms and links to samples of the forms are available below. To view a sample form, click the form name.

Claim Type	Where To Get Them
Professional - CMS-1500	Business Form Supplier
Institutional-CMS-1450*	Business Form Supplier
EPSDT - DMS-694**	EDS- 1-800-457 -4454
Visual Care - DMS-26-V	EDS- 1-800-457 -4454
Inpatient Crossover- EDS-MC-001	EDS- 1-800-457 -4454
Long Term Care Crossover - EDS-MC-002	EDS- 1-800-457 -4454
Outpatient Crossover - EDS-MC-003	EDS- 1-800-457 -4454
Professional Crossover - EDS-MC-004	EDS- 1-800-457 -4454

* For dates of service after 11/30/07 - ALL HOSPICE PROVIDERS USE ONLY FORM CMS-1450 (formerly (UB-04) for billing.

** A printable PROVIDER INTEROFFICE DOCUMENTATION ONLY version of this form is available below under Arkansas Medicaid Forms.

Claim Forms

The following is a list of the non-red-ink claim forms required by Arkansas Medicaid. Information about where to get a supply of the forms and links to samples of the forms are available below. To view a sample form, click the form name.

Claim Type	Where To Get Them
Alternatives Attendant Care Provider Claim Form -AAS-9559	Client Employer
Dental - ADA-J400	Business Form Supplier

Arkansas Medicaid Forms

The forms below can be printed from this manual for use.

In order by form name:

Form Name	Form Number
Acknowledgement of Hysterectomy Information	DMS-2606
Address Change Form	DMS-673
Adjustment Request Form - Medicaid XIX	EDS-AR-004
AFMC Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components	AFMC-103
AFMC Request For Bilaminate Skin Substitutes	AFMC-RBSS
Amplification/Assistive Technology Recommendation Form	DMS-686
Approval/Denial Codes for Inpatient Psychiatric Services	DMS-2687
Arkansas Early Intervention Infant & Toddler Program Intake/Referral/Application for Services	DDS/FS#0001.a
ARKids First Mental Health Services Provider Qualification Form	DMS-612
Assisted Living Waiver Plan of Care	AAS-9565
Authorization for Automatic Deposit	autodeposit
Authorization for Payment for Services Provided	MAP-8
Certification of Need - Medicaid Inpatient Psychiatric Services for Under Age 21	DMS-2633
Certification of Schools to Provide Comprehensive EPSDT Services	CSPC-EPSDT
Certification Statement for Abortion	DMS-2698
Change of Ownership Information	DMS-0688
CHMS Benefit Extension for Diagnosis/Evaluation Procedures	AFMC-102
CHMS Request for Prior Authorization	AFMC-101
Claim Correction Request	DMS-2647
Consent for Release of Information	DMS-619
Contact Lens Prior Authorization Request Form	DMS-0101
Contract to Participate in the Arkansas Medical Assistance Program	DMS-653
DDTCS Transportation Log	DMS-638
DDTCS Transportation Survey	DMS-632
Dental Treatment Additional Information	DMS-32-A
Disclosure of Significant Business Transactions	DMS-689
Disproportionate Share Questionnaire	DMS-628
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Prescription/Referral For Medically Necessary Services/Items Not Specifically Included in the Medicaid State Plan	DMS-693
Early Childhood Special Education Referral Form	ECSE-R
EPSDT Claim Form - You may print this version for use in charts and electronic billing documentation; however, if you submit a paper claim for billing, you must use the red-ink version (see Red-ink Claim Forms above.)	EPSDT-DMS-694
EPSDT Provider Agreement	DMS-831
Evaluation Form Lower-Limb	DMS-646
Explanation of Check Refund	EDS-CR-002
Gait Analysis Full Body	DMS-647
Home Health Certification and Plan of Care	CMS-485
Hospital/Physician/Certified Nurse Midwife Referral for Newborn Infant Medicaid Coverage	DCO-645
Inpatient Psychiatric Medicaid Agency Review Team Transmittal Sheet	DMS-2685
Lower-Limb Prosthetic Prescription	DMS-651
Media Selection/E-Mail Address Change Form	None
Medicaid Claim Inquiry Form	EDS-CI-003
Medicaid Form Request	EDS-MFR-001
Medical Assistance Dental Disposition	DMS-2635
Medical Equipment Request for Prior Authorization & Prescription	DMS-679
Medical Transportation and Personal Assistant Verification	DMS-616
Mental Health Services Provider Qualification Form for LCSW, LMFT and LPC	DMS-633
Notice Of Noncompliance	DMS-635
NPI Reporting Form	DMS-683
Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21 Prescription/Referral	DMS-640
Ownership and Conviction Disclosure	DMS-675
Personal Care Assessment and Service Plan	DMS-618
Practitioner Identification Number Request Form	DMS-7708
Prescription & Prior Authorization Request For Nutrition Therapy & Supplies	DMS-2615
Primary Care Physician Managed Care Program Referral Form	DMS-2610
Primary Care Physician Participation Agreement	DMS-2608
Primary Care Physician Selection and Change Form	DMS-2609
Prior Authorization (PA) Request for Extension of Benefits-Prescription Drugs	DMS-0685-14
Procedure Code/NDC Detail Attachment Form	DMS-664
Prosthetic-Orthotic Lower-Limb Amputee Evaluation	DMS-650
Prosthetic-Orthotic Upper-Limb Amputee Evaluation	DMS-648
Provider Application	DMS-652
Provider Communication Form	AAS-9502
Provider Data Sharing Agreement- Medicare Parts C & D	DMS-652-A
Provider Enrollment Application and Contract Package	AppMaterial
Referral for Certification of Need Medicaid Inpatient Psychiatric Services for Under Age 21	DMS-2634
Referral for Medical Assistance	DMS-630
Request for Extension of Benefits	DMS-699
Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services	DMS-671
Request for Extension of Benefits for Medical Supplies for Medicaid Beneficiaries Under Age 21	DMS-602
Request For Orthodontic Treatment	DMS-32-0
Request for Private Duty Nursing Services Prior Authorization and Prescription - Initial Request or Recertification	DMS-2692
Request for Targeted Case Management Prior Authorization for Beneficiaries Under Age 21	DMS-601
Sterilization Consent Form	DMS-615 English DMS-615 Spanish
Sterilization Consent Form - Information for Men	PUB-020
Sterilization Consent Form - Information for Women	PUB-019
Upper-Limb Prosthetic Prescription	DMS-649
Vendor Performance Report	None
Verification of Medical Services	DMS-2618

In order by form number:

AAS-9502	DMS-2606	DMS-602	DMS-650	DMS-699
AAS-9565	DMS-2608	DMS-612	DMS-651	DMS-7708
Address	DMS-2609	DMS-615	DMS-652	DMS-831
Change	DMS-2610	DMS-616	DMS-652-A	ECSE-R
AFMC-101	DMS-2615	DMS-618	DMS-653	EDS-AR-004
AFMC-102	DMS-2618	DMS-619	DMS-664	EDS-CI-003
AFMC-103	DMS-2633	DMS-628	DMS-671	EDS-CR-002
AFMC-RBSS	DMS-2634	DMS-630	DMS-675	EDS-MFR-001
Authorization for Automatic	DMS-2635	DMS-632	DMS-673	MAP-8
Deposit	DMS-2647	DMS-633	DMS-679	Report
CMS-485	DMS-2685	DMS-635	DMS-683	Provider
CSPC-EPSDT	DMS-2687	DMS-638	DMS-686	Enrollment
DCO-645	DMS-2692	DMS-640	DMS-689	Application and Contract
DDS/FS#0001.a	DMS-2698	DMS-646	DMS-693	Package
DMS-0101	DMS-32-A	DMS-647	DMS-694 chart	PUB-019
DMS-0685-14	DMS-32-0	DMS-648	version	PUB-020
DMS-0688	DMS-601	DMS-649	DMS-694 sample

Arkansas Medicaid Contacts and Links

Click the link to view the information.

American Hospital Association

Americans with Disabilities Act Coordinator

APS Healthcare Midwest (APS)

Arkansas Department of Education, Health and Nursing Services Specialist

Arkansas Department of Education, Special Education

Arkansas Department of Human Services - Aging and Adult Services

Arkansas Department of Human Services - Appeals and Hearings Section

Arkansas Department of Human Services, Child Care and Early Childhood Education, Child Care Licensing Unit

Arkansas Department of Human Services, Children and Family Services, Contracts Management Unit

Arkansas Department of Human Services, Children's Services

Arkansas Department of Human Services, County Operations - Customer Assistance Section

Arkansas Department of Human Services, Medical Services

Arkansas Department of Human Services, Medical Services, Dental Care Unit

Arkansas Department of Human Services, Medical Services Director

Arkansas Department of Human Services, Medical Services, Financial Activities Unit

Arkansas Department of Human Services, Medical Services, Hearing Aid Consultant

Arkansas Department of Human Services, Medical Services, Medical Assistance Unit

Arkansas Department of Human Services, Medical Services, Pharmacy Unit-Utilization Review Section

Arkansas Department of Human Services, Medical Services, Program Communications Unit

Arkansas Department of Human Services, Medical Services, Third-Party Liability Unit

Arkansas Department of Human Services, Medical Services, UR Benefit Extension Reguests Section

Arkansas Department of Human Services, Medical Services, UR/Home Health Extensions

Arkansas Department of Human Services, Medical Services, Utilization Review Section

Arkansas Department of Human Services, Medical Services, Visual Care Coordinator

Arkansas Department of Human Services, Medical Services, Provider Reimbursement Unit

Arkansas Department of Health

Arkansas Department of Health, Health Facility Services

Arkansas Department of Human Services, Accounts Receivable

Arkansas Foundation For Medical Care

Arkansas Hospital Association Contact Information

Arkansas Medicaid Provider Enrollment Unit

ARKids First-B ID Card Example

ARKids First-B Telephone Number

Child Health Services (EPSDT)

ConnectCare Helpline

County Codes

CPT Ordering Information

EDS Claims Department

EDS EDI Support Center (formerly AEVCS Help Desk)

EDS Inquiry Unit

EDS Manual Order Address

EDS Pharmacy Help Desk

EDS Provider Assistance Center (PAC)

EDS Supplied Forms

Example of Beneficiary Notification of Denied ARKids First-B Claim

Example of Beneficiary Notification of Denied Medicaid Claim

First Connections Infant & Toddler Program Developmental Disabilities Services

First Health

Flow Chart of Intake and Prior Authorization Process For Intervention/Treatment

Health Care Declarations

ICD-9-CM Ordering Information

Immunizations Registry Help Desk - Arkansas Department of Health

Medicaid ID Card Example

Medicaid Reimbursement Unit Communications Hotline

Medicaid Tooth Numbering System

National Supplier Clearinghouse

Primary Care Physician (PCP) Enrollment Voice Response System

Provider Qualifications Division of Mental Health Services

QSource of Arkansas

Select Optical

Standard Register

Table of Desirable Weights

U.S. Government Printing Office

Vendor Performance Report

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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Arkansas Administrative CodeAgency 016 - DEPARTMENT OF HUMAN SERVICESDivision 06 - Medical ServicesRule 016.06.08-032 - Section V Provider Manual Update Transmittal

Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.08-032 - Section V Provider Manual Update Transmittal