Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.10-017 - Official Notice ON-004-10: CMS-1500 Replaces DMS-694 for EPSDT Screenings or Services
Health Care Providers - Child Health Services (EPSDT), Certified Nurse- Midwife, Dental, Hearing, Licensed Mental Health Practitioner, Nurse Practitioner, Physician, Visual Care,December 1, 2010,CMS-1500 Replaces DMS-694 for EPSDT Screenings or Services
Effective for dates of service on or after 12/1/10, form DMS-694 is discontinued and will no longer be available for EPSDT screenings or services. Form CMS-1500 will capture the EPSDT screenings or services for paper claims in the following manner:
* For all EPDST paper claim submissions, please enter the letters EPSDT in BOX 10-D on the CMS-1500 claim form.
* If the EPSDT screening/service resulted in a referral or prescription for additional services, enter the appropriate Reason Code listed below in the upper shaded part of the detail line 24-H.
* EPSDT Reason Codes are required when billing for EPSDT screenings/services. The code should indicate actions taken as a result of the screening. Please enter the appropriate 2-byte Reason Code in the upper shaded part of the detail line 24-H.
If a Y is entered instead of the required Reason Code indicated below, the claim will deny.
o AV - Available - Not Used (patient refused referral)
o NU - Not Used (used when no EPSDT patient referral was given)
o S2 - Under Treatment (patient is currently under treatment for referred diagnostic or corrective health problem)
o ST - New Service Requested (referral to another provider for diagnostic or corrective treatment/scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service, not including dental referrals.)
Non-EPSDT screening services, i.e., sick visits, cannot be billed on the same claim form as EPSDT services.
If you have questions regarding this notice, please contact the HP Enterprise Services Provider Assistance Center at In-State WATS 1-800-457 -4454, or locally and Out-of-State at (501) 376-2211.
If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at 501-682-0593 (Local); 1-800-482 -5850, extension 2-0593 (Toil-Free) or to obtain access to these numbers through voice relay, 1-800-877 -8973 (TTY Hearing Impaired).
Arkansas Medicaid provider manuals, official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.
Thank you for your participation in the Arkansas Medicaid Program.
