Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.21-006 - Technical Corrections-Vendor Name Removal from Medicaid Provider Manuals

215.120 Benefit Extension Requests 8-1-21

215.123 Provider Notification of Benefit Extension Determinations 8-1-21

Approval or denial of a benefit extension request-or request for additional information-will be made within thirty (30) calendar days.

Reviewers will simultaneously advise the provider and the beneficiary when a benefit extension request is denied.

221.000 Prior Authorization Information 8-1-21

221.100 Prior Authorization Request and Notification Procedures 8-1-21

The procedures in this section apply to all requests for prior authorization (PA) of outpatient surgeries.

214.100 Extension of Benefits for X-Ray Services 8-1-21

214.110 Completion of Request Form DMS-671, "Request For Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services" 8-1-21

Requests for extension of benefits for Clinical Services (Physician's Visits), Outpatient Services (Hospital Outpatient visits), Laboratory Services (Lab Tests) and X-ray services (X-ray, Ultrasound, Electronic Monitoring - e.e.g.; e.k.g.; etc), must be submitted to DHS or its designated vendor for consideration. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting extension of benefits.

Consideration of requests for extension of benefits requires correct completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray (form DMS-671). View or print form DMS-671.

Complete instructions for accurate completion of form DMS-671 (including indication of required attachments) accompany the form.

214.200 Administrative Reconsideration of Extensions of Benefits Denial 8-1-21

201.600 Dentist Role in the Pharmacy Program 8-1-21

Medicaid covers prescription drugs in accordance with policies and regulations set forth in this section and pursuant to orders (prescriptions) from authorized prescribers. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. A numeric listing of approved pharmaceutical companies and their respective labeler codes is located on the Arkansas Division of Medical Services (DMS) Pharmacy website. View or print numeric listing of approved pharmaceutical companies and the respective labeler codes. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with listed labeler codes.

PRESCRIPTION DRUG INFORMATION

View or print contact information for prescription drug prior authorization concerns and the latest information regarding prescription drug coverage.

236.000 Prescription Prior Authorization 8-1-21

Prescription drugs are available for reimbursement under the Arkansas Medicaid Program pursuant to an order from an authorized prescriber. Certain prescription drugs may require prior authorization.

The dental provider must request prior authorization before prescribing a prescription drug to an eligible Medicaid beneficiary.

View or print contact information for information relative to the following:

261.000 Introduction to Billing 8-1-21

Dental providers must use the American Dental Association (ADA) form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one (1) beneficiary.

Section III of the Arkansas Medicaid provider manual contains information about available options for electronic claim submission. When billing electronically, the provider's NPI number is required.

262.400 Billing Instructions - ADA Claim Form - Paper Claims Only 8-1-21

Dental providers must complete the ADA claim form when:

202.200 The FQHC's Role in the Arkansas Medicaid Pharmacy Program 8-1-21

Medicaid covers prescription drugs in accordance with rules set forth in this section (Section 202.200) and pursuant to orders (prescriptions) from authorized prescribers. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with current rebate agreements and listed labeler codes.

Click here to obtain the latest information regarding prescription drug coverage.

220.201 Benefit Extension Requests 8-1-21

220.204 Provider Notification of Benefit Extension Determinations 8-1-21

Approval or denial of a benefit extension request-or request for additional information-will be made within thirty (30) calendar days.

204.210 Availability of ESRD Medical Records 8-1-21

The Arkansas Department of Health and Human Services, its designees and other state and federal agencies review medical records for documentation of services provided and billed and to evaluate the medical necessity of delivered services.

212.401 Inpatient Hospital Services Benefit Limit 8-1-21

212.500 Medicaid Utilization Management Program (MUMP) 8-1-21

212.501 Length of Stay Determination 8 -1-21

212.502 Reconsiderations 8-1-21

Once per admission DHS or the designated vendor will reconsider a denied extension.

212.503 Paper Review After Reconsiderations: Special Cases 8-1-21

212.510 MUMP Applicability 8-1-21

212.520 MUMP Certification Request Procedure 8-1-21

When a patient is transferred from another hospital (see Section 212.530 below) or when a patient's attending physician determines the patient should not be discharged by the fifth day of hospitalization, hospital utilization review or case management personnel may request an extension of inpatient days. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting MUMP certification.

212.530 Transfer Admissions 8-1-21

When a patient is transferred from one hospital to another, the receiving facility must contact DHS or designated contractor within twenty-four (24) hours of admission to certify the inpatient stay. View or print contact information to obtain instructions for submitting the transfer request.

212.540 Post Certification Due to Retroactive Eligibility 8-1-21

When eligibility is determined while the patient is still an inpatient, the hospital may request postcertification of inpatient days beyond the first four (4) (or all days if the admission was by transfer) and a concurrent certification of additional days, if needed. View or print contact information to obtain instructions for submitting the request.

212.550 Third Party and Medicare Primary Claims 8-1-21

If a provider did not request MUMP certification of an inpatient stay because of apparent coverage by insurance or Medicare Part A, but the other payer has denied the claim for noncovered service, lost eligibility, benefits exhausted etc., post-certification required by the MUMP may be obtained. View or print contact information to obtain instructions for submitting the request.

215.100 Benefit Extension Requests 8-1-21

215.103 Provider Notification of Benefit Extension Determinations 8-1-21

Approvals or denials of a benefit extension request-or ask for additional information-shall be made within thirty (30) calendar days.

215.420 CAH Coverage Restrictions 8-1-21

217.060 Transplants 8-1-21

217.063 Heart Transplants 8-1-21

217.064 Liver Transplants 8-1-21

217.065 Liver/Bowel Transplants 8-1-21

217.066 Lung Transplants 8-1-21

217.130 Hyperbaric Oxygen Therapy (HBOT) 8-1-21

Hyperbaric Oxygen Therapy (HBOT) involves exposing the body to oxygen under pressure greater than one atmosphere. Such therapy is performed in specially constructed hyperbaric chambers holding one or more patients, although, oxygen may be administered in addition to the hyperbaric treatment itself. Patients should be assessed for contraindications such as sinus disease or claustrophobia prior to therapy. In some diagnoses, hyperbarics is only an adjunct to standard surgical therapy. These indications are taken from "The Hyperbaric Oxygen Therapy Committee Report" (2003) of The Undersea and Hyperbaric Medical Society (Kensington, MD).

HBOT prior authorizations will be issued by DHS or its designated vendor. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting prior authorization. All hyperbaric oxygen therapy will require prior authorization, except in emergency cases such as for air embolism or carbon monoxide poisoning, in which post-authorization will be allowed per protocol. See Section 242.000. Prior authorization will be issued for a specific number of treatments. Subsequent treatments will require another review and an additional prior authorization. The caller must be able to provide demographic and clinical information to support the medical necessity of treatment. All information that is submitted to acquire the prior authorization must be documented in the beneficiary's medical record. View or print contact information to obtain instructions for submitting the request for prior authorization.

NOTE: When approved, only one authorization will be issued. The prior authorization and the number of approved HBOT treatments must be communicated to the physician provider so that both the facility and physician may claim reimbursement for the number of approved HBOT sessions. Additionally, if more HBOT sessions are required for the same beneficiary, a new prior authorization is required. A new prior authorization number will be assigned for any additional sessions approved. The prior authorization information between the facility and the physician must be reciprocal if the physician acquires the prior authorization.

The following table provides the diagnosis requirements, description of the problem, and number of treatments.

Refer to Section 272.404 of this manual for billing instructions.

218.000 Guidelines for Retrospective Review of Occupational, Physical and Speech Therapy Services 8-1-21

DHS or its designated vendor performs retrospective reviews of medical records to determine the medical necessity of services paid for by Medicaid. View or print contact information to obtain the DHS or designated vendor retrospective reviews.

Specific guidelines have been developed for retrospective review of occupational, physical and speech-language therapy services furnished to Medicaid beneficiaries under the age of twenty-one (21). These guidelines are included in this manual to assist providers in determining and documenting the medical necessity of occupational, physical and speech-language therapy services and are found in Sections 218.100 through 218.110

218.250 Process for Requesting Extended Therapy Services for Beneficiaries Under Age 21 8-1-21

218.270 Extended Therapy Services Review Process 8-1-21

View or print contact information to obtain the DHS or designated vendor step-by-step process for extended therapy services review.

218.280 Administrative Reconsideration 8-1-21

A request for administrative reconsideration of the denial of services must be in writing and sent to DHS or its designated vendor within thirty (30) calendar days of the denial. The request must include a copy of the denial letter and additional supporting documentation.

The deadline for receipt of the reconsideration request will be enforced pursuant to Sections 190.012 and 190.013 of the manual. A request received within thirty-five (35) calendar days of a denial will be deemed timely

241.000 Procedures for Obtaining Prior Authorization 8-1-21

There are certain medical, diagnostic and surgical procedures that are not covered without prior authorization, either because of federal requirements or because of the elective nature of a procedure. DHS or its designated vendor makes prior authorization (PA) determinations for most Medicaid-covered surgical procedures that require PA, and for some lab procedures that require PA.

Please refer to Section 244.000 of this manual for a list of procedures requiring prior authorization.

Prior authorization determinations are made utilizing established medical or administrative criteria combined with the professional judgment of physician advisors.

View or print contact information to obtain the DHS or designated vendor step-by-step process for prior authorization.

If surgery is involved, a copy of the authorization will be sent to the hospital where the service will be performed. If the hospital has not received a copy of the authorization before the time of admission, the hospital will contact the admitting physician or DHS or its designated vendor to verify that prior authorization has been granted.

It is the responsibility of the primary surgeon to distribute a copy of the authorization to the assistant surgeon if the assistant has been requested and approved.

Prior authorization of service does not guarantee eligibility for a beneficiary. Coverage is contingent on the beneficiary's eligibility on the date(s) of service.

242.000 Post-authorization for Emergency Procedures and Periods of Retroactive Eligibility 8-1-21

Post-authorization will be granted only for emergency procedures or retroactively eligible beneficiaries.

243.000 Post Procedural Authorization for Eligible Beneficiaries Under Age 21 8-1-21

Providers performing surgical procedures that require prior authorization are allowed sixty 60 days from the date of service to obtain prior authorization if the beneficiary is under age twenty-one (21).

All requests for post-procedural authorizations for eligible beneficiaries are to be made to DHS or its designated vendor within sixty (60) days of the date of service. These calls will be tape-recorded. View or print contact information to obtain the DHS or designated vendor step-by-step process for extension of benefits review.

The beneficiary and provider identifying criteria and all of the medical data necessary to justify the procedures must be provided.

Consulting physicians are responsible for contacting DHS or its designated vendor to have procedures added to the PA file. Providers must obtain prior authorization for procedures requiring authorization in order to prevent risk of denial due to lack of medical necessity.

This policy applies only to those Medicaid beneficiaries under age twenty-one (21). This policy does not alter prior authorization procedures applicable to retroactive eligible beneficiaries.

245.010 Organ Transplant Prior Approval in Arkansas and Bordering States 8-1-21

The attending physician is responsible for obtaining prior approval for organ transplants.

245.020 Organ Transplant and Evaluation Prior Approval in Non-Bordering States 8-1-21

245.030 Hyperbaric Oxygen Therapy (HBOT) Prior Authorization 8-1-21

All hyperbaric oxygen therapy will require prior authorization, except in emergency cases such as for air embolism or carbon monoxide poisoning, in which post-authorization will be allowed per protocol. See Section 242.000. Prior authorization will be for a certain number of treatments. Further treatments will require reapplication for a prior authorization. In order to request a prior authorization for HBOT, the provider must contact DHS or its designated vendor. View or print contact information to obtain instructions for submitting the prior authorization request.

Refer to Sections 217.130, 242.000, 252.119, and 272.404 for additional information on HBOT.

250.713 Other Covered Transplants in all Hospitals Except In-State Pediatric Hospitals and Arkansas State-Operated Teaching Hospitals 8-1-21

250.714 Other Covered Transplants in In-State Pediatric Hospitals and Arkansas State-Operated Teaching Hospitals 8-1-21

272.449 Molecular Pathology 8-1-21

Molecular Pathology procedure codes require prior authorization (PA). Providers must receive prior authorization before a claim for molecular pathology is filed for payment. Providers may request the PA from DHS or its designated vendor before or after the procedure is performed as long as it is acquired in time to receive approval and file a clean claim within the 365-day claims filing deadline. View or print contact information to obtain the DHS or designated vendor step-by-step process to request prior authorization.

Molecular Pathology PA requests must be submitted by the performing provider with submission of a completed Arkansas Medicaid Request for Molecular Pathology Laboratory Services (form DMS-841) and all pertinent clinical documentation needed to justify the procedure.

Reconsideration of denied requests is allowed if new or additional information is received within thirty (30) days of the initial denial. View or print form DMS-841. This form may be found in Section V of the provider manual. Do not complete the form unless you are submitting a Molecular Pathology PA request.

Molecular Pathology procedure codes must be submitted on a red line paper claim form with the PA number listed on the claim and the itemized invoice attached that supports the charges for the test billed. See Section 244.000 for Molecular Pathology procedure codes.

221.000 Prior Authorization 8-1-21

Hyperalimentation fluids, equipment and supplies must be prior authorized by the Department of Human Services (DHS) or its designated vendor. View or print contact information to obtain the DHS or its designated vendor step-by-step process for requesting prior authorization.

222.000 Request for Prior Authorization 8-1-21

Requests for prior authorization originate with the provider. The provider is responsible for obtaining the required medical information and necessary prescription information needed for completion of the Request for Prior Authorization and Prescription Form. View or print form DMS-2615 and instructions for completion. This form must be signed and dated by the prescribing physician.

The request for prior authorization will be reviewed by the Department of Human Services (DHS) or its designated vendor. The documentation submitted with the prior authorization request must support the medical necessity of the requested nutritional therapy. In some cases, additional information may be requested (i.e., original prescription, records from the hospitalization initiating nutritional therapy, nutritional assessment to establish medical necessity for nutritional therapy, etc.).

222.100 Approvals of Prior Authorization Requests 8-1-21

When the PA request is approved, a prior authorization control number will be assigned. Prior authorization approvals are authorized for a maximum of six (6) months (180 days) or for the life of the prescription, whichever is shorter. If the prescribing physician documents the beneficiary's condition is chronic and unlikely to change, a prior approval may be authorized for a maximum of twelve (12) months. The effective date of the prior authorization will be the date the patient will begin therapy or the day following the last day of the previous authorization approval.

223.000 Pre-Approval of Hyperalimentation Services 8-1-21

When an eligible Medicaid beneficiary is discharged from the inpatient setting with the continuation of hyperalimentation services in the home, a provider may request a pre-approval for hyperalimentation before the anticipated discharge date. View or print contact information to obtain the DHS or its designated vendor step-by-step process for requesting preapproval for hyperalimentation.

When approved, a prior authorization number will be assigned and will be effective for thirty (30) days. The provider must not bill for hyperalimentation services prior to the date of discharge or bill for services on the same dates of service as the inpatient stay.

If the beneficiary is not discharged within the thirty (30) days, the pre-approval will be void.

When continuation of the therapy is required past the initial thirty (30) day pre-approval, the provider must submit a recertification for prior authorization request with a prescription signed by the prescribing physician, prior to the end date of the pre-approval.

A pre-approval of hyperalimentation services does not guarantee payment.

203.100 The Nurse Practitioner's Role in the Pharmacy Program 8-1-21

Medicaid covers prescription drugs in accordance with policies and regulations set forth in this section and pursuant to orders (prescriptions) from authorized prescribers. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) which was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. A numeric listing of approved pharmaceutical companies and their respective labeler codes is located on the Arkansas Division of Medical Services (DMS) Pharmacy website. View or print numeric listing of approved pharmaceutical companies and their respective labeler codes. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with listed labeler codes.

An advanced nurse practitioner with prescriptive authority (verified by the Certificate of Prescriptive Authority Number issued by the licensing authority of the state in which services are furnished) may only prescribe legend drugs and controlled substances identified in the state licensing rules and regulations. Medicaid reimbursement will be limited to prescriptions for drugs in these schedules.

Prescribers must obtain the latest information regarding prescription drug coverage at the website listed in the contact information for DHS or its designated Pharmacy Vendor. View or print contact information for the DHS designated Pharmacy Vendor.

203.600 The Nurse Practitioner's Role in Hospital Services 8-1-21

214.510 Laboratory and X-Ray Services Benefit Limits 8-1-21

The Medicaid Program's laboratory and X-ray services benefit limits apply to outpatient laboratory services, radiology services and machine tests.

214.711 Medicaid Utilization Management Program (MUMP) 8-1-21

The Medicaid Utilization Management Program (MUMP) determines covered lengths of stay in inpatient acute care and/or general hospitals, in state and out of state.

Length-of-stay determinations are made by the Quality Improvement Organization (QIO), under contract to the Arkansas Medicaid Program.

Individuals in all Medicaid eligibility categories and all age groups, except beneficiaries under age one (1), are subject to this policy. Medicaid beneficiaries under age one (1) at the time of admission are exempt from the MUMP policy for dates of service before their first birthday.

Refer to item "E" below for the procedure to follow when a child's first birthday occurs during an inpatient stay.

The procedures for the MUMP are as follows:

214.910 Extension of Benefits for Laboratory and X-Ray Services 8-1-21

214.920 Completion of Request Form DMS-671, "Request For Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services." 8-1-21

Requests for extension of benefits for Clinical Services (Physician's visits, Nurse Practitioner visits), Outpatient Services (Hospital Outpatient visits), Laboratory Services (Lab Tests) and X-ray services (X-ray, Ultrasound, Electronic Monitoring - e.e.g.; e.k.g.; etc.), must be submitted to DHS or designated vendor for consideration. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting extension of benefits.

Consideration of requests for extension of benefits requires correct completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray (form DMS-671). View or print form DMS-671.

Complete instructions for accurate completion of form DMS-671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each provider manual.

214.940 Reconsideration of Extensions of Benefits Denial 8-1-21

221.000 Procedure for Obtaining Prior Authorization 8-1-21

221.100 Post-Procedural Authorization 8-1-21

Post-procedural authorization will be granted only for emergency procedures for beneficiaries age twenty-one (21) and older. Requests for post-authorization of an emergency procedure must be applied for on the first working day after the procedure is performed.

In cases of retroactive eligibility, the provider must contact DHS or its designated vendor for post-authorization within sixty (60) days of the eligibility authorization date displayed in the electronic eligibility verification response.

221.110 Post-Procedural Authorization Process for Beneficiaries Under Age 21 8-1-21

221.200 Prescription Prior Authorization 8-1-21

Prescription drugs are available for reimbursement under the Arkansas Medicaid Program when prescribed by a nurse practitioner with prescriptive authority. Certain prescription drugs may require prior authorization. It is the responsibility of the prescriber to request and obtain the prior authorization. Information may be obtained from DHS or its designated vendor. View or print contact information to obtain the DHS or designated vendor prescription drug information.

The following information is available:

252.131 Molecular Pathology 8-1-21

The following Molecular Pathology codes require prior authorization from DHS or its designated vendor. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting prior authorization.

252.453 Fluoride Varnish Treatment 8-1-21

The American Dental Association (ADA) procedure code D1206 is covered by the Arkansas Medicaid Program. This code is payable for beneficiaries under the age of twenty-one (21). Topical fluoride varnish application benefit is covered every six (6) months plus one (1) day for beneficiaries under age twenty-one (21).

A new specialty code, FC-Fluoride Certification will be tied to provider types 01, 03, 58 and 69. These providers must send proof of their fluoride varnish certification to DHS or its designated vendor before the specialty code will be added to their file in the MMIS. View or print contact information to obtain the DHS or designated vendor step-by-step process for provider enrollment. After the specialty code, FC-Fluoride Certification, is added to the provider's file, the provider will be able to bill for procedure code D1206, Topical Application of Fluoride Varnish.

Providers must check the Supplemental Eligibility Screen to verify that topical fluoride varnish benefit of two (2) per State Fiscal Year (SFY) has not been exhausted. If further treatment is needed due to severe periodontal disease, then the beneficiary must be referred to a Medicaid dental provider.

NOTE: This service is billed on form CMS-1500 with ADA procedure code D1206 (Topical application of fluoride varnish (prophylaxis not included) - child (ages 0-20)).

View a form CMS-1500 sample form.

252.484 Injections, Therapeutic and/or Diagnostic Agents 8-1-21

Nurse practitioners shall administer injections, therapeutic and diagnostic agents in accordance with the rules set forth in the Arkansas Medicaid Physician's policy manual and within the scope of their practice guidelines.

200.000 DEFINITIONS 8-1-21

212.000 Practice Enrollment 8-1-21

Enrollment in the PCMH program is voluntary and practices must re-enroll annually. To enroll, practices must access the Advanced Health Information Network (AHIN) provider portaland submit a complete and accurate Arkansas Medicaid Patient-Centered Medical Home Practice Participation Agreement (DMS-844).

Once enrolled, a participating PCMH remains in the PCMH program until:

234.000 Requirements for Joining and Leaving Pools 8-1-21

PCMHs may voluntarily pool for purposes described in Section 233.000 before the end of the enrollment period that precedes the start of the performance period. To pool, the participating practice must email a complete and accurate Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Form (DMS-845) to the Fiscal Contractor. View or print the Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Form on the APII website. You can also download the form from the AHIN provider portal.

The DMS-845 Pooling form must be executed by all PCMHs participating in the pool. Before the end of the enrollment period, PCMHs that are on their own or through pooling do not reach a minimum of 1,000 attributed beneficiaries will be assigned to the default pool. Practices with less than 300 attributed beneficiaries that do not wish to participate in a voluntary pool will be placed in the petite pool. Individual PCMHs whose attribution changes during the performance period will be classified as standalone, default, or petite pool members according to their attribution count at the end of the performance period.

Pooling is effective for a single performance period and must be renewed for each subsequent year.

When a PCMH has voluntarily pooled, its performance is measured in the associated shared performance entity throughout the duration of the performance period unless it withdraws from the PCMH program during the performance period. When a PCMH in a voluntary pool withdraws, is suspended, or otherwise leaves the PCMH program, any and all PCMHs in the shared performance entity will have their performance measured as if the withdrawn or suspended PCMH had never participated in the pool. This provision does not apply to PCMHs that leave the program in the last calendar quarter. If the PCMH leaves the program in the last calendar quarter, the departing PCMH, and its performance will be treated as if the PCMH has not left the program.

212.000 Exclusions 8-1-21

213.100 Monthly Prescription Limits 8-1-21

216.200 Prescription Benefits for Long-Term Care Facility Residents 8-1-21

Prescriptions for Medicaid-eligible LTC facility residents are not subject to a monthly prescription limit; however, the drug product must be covered under the Arkansas Medicaid Pharmacy Program. Information is available from DHS or its contracted Pharmacy Vendor. View or print the DHS Contracted Pharmacy Vendor Help Desk contact information.

218.000 Participating Manufacturer/Distributor Listing 8-1-21

Due to the importance of maintaining accurate prices in the drug master file, it is necessary that drug companies keep various drug pricing contractors informed of all product and price revisions. The Arkansas Medicaid Program's fiscal agent contracts with a national compendia to provide pricing information. It is the pharmacists' responsibility to contact the DHS contracted Pharmacy Vendor's Help Desk to determine if a manufacturer's products are listed in the national compendia drug file. View or print the DHS Contracted Pharmacy Vendor Help Desk contact information.

240.000 PRIOR AUTHORIZATION 8-1-21

Prescription drugs may be reimbursed under the Arkansas Medicaid Program pursuant to an order from an authorized prescriber.

The prescriber must initiate the prior authorization (PA) for prescription drugs that require PA. The PA request must be completed and submitted by the prescriber. All PA documentation must remain in the patient's chart and will be subject to audit by the Division of Medical Services or its authorized representatives.

In addition, clinical edits will be established through a system modification enhancement, as well as limits placed on drugs based on age, gender, quantity and dosage, as approved by our Drug Utilization Review Board. Lists of all drugs subject to clinical editing and the criteria for reimbursement are maintained by DHS or its contracted Pharmacy Vendor View or print the DHS Contracted Pharmacy Vendor Help Desk contact information.

Arkansas Medicaid Pharmacy Program will maintain a Preferred Drug List based on comparative evidence-based data from Clinical Evidence Reports (CER). Arkansas Medicaid Pharmacy Program will use the CER to identify drug class or drug classes of medications that have similar indications, efficacy, and safety. Arkansas Medicaid will negotiate state supplemental rebates with manufacturers for the identified medication(s) pursuant to a CMS approved State Supplemental Rebate Agreement. A Drug Cost Committee (DCC) will review both State Supplemental and Federal rebates to determine the final net cost to the State of the identified medication(s). A Drug Review Committee (DRC) will review the CER to determine safety and efficacy of the identified medication(s). The DCC and DRC will provide recommendations to the State for preferred and non-preferred status for the identified medication(s). Arkansas Medicaid will use these recommendations to establish and maintain a Preferred Drug List.

In an emergency, for those drugs for which a five-day supply can be dispensed, an Arkansas Medicaid enrolled pharmacy may dispense up to a five-day supply of a drug that requires prior authorization. This provision applies only in an emergency situation when the DHS Contracted Pharmacy Vendor Help Desk and the State Medicaid Pharmacy Program offices are closed, and the pharmacist is not able to contact the prescribing provider to change the prescription. The Emergency Supply Policy does not apply to drugs that are not covered by the State. Frequency of the emergency override is limited to once per year per drug class for non-LTC beneficiaries and once per sixty (60) days per drug class for LTC beneficiaries. To file a claim using this emergency provision, the pharmacy provider will submit a "03" in the Level of Service (418-DI) field.

Prior Authorization information is maintained by DHS or its contracted Pharmacy Vendor. View or print the DHS Contracted Pharmacy Vendor Help Desk contact information.

The following information is available:

251.200 Brand Medically Necessary Override 8-1-21

The prescriber must determine whether the Medicaid beneficiary meets the required conditions to override an Upper Limit (FUL, SAAC, Generic NADAC). The prescriber must also complete the required MedWatch (see below) documentation to allow a prior authorization (PA) for a "Brand Medically Necessary" override of the Upper Limit to reimburse at the brand name reimbursement rate.

MedWatch is the Food and Drug Administration (FDA) Safety Information and Adverse Event Reporting Program that allows healthcare professionals to report serious problems that they suspect are associated with certain drugs they prescribe.

The following criteria must be met to override the Upper Limit when calculating the allowable amount of reimbursement:

203.170 Physician's Role in Hospital Services 8-1-21

203.230 Physician's Role in the Pharmacy Program 8-1-21

Medicaid covers prescription drugs in accordance with policies and regulations set forth in this section and pursuant to orders (prescriptions) from authorized prescribers. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. A numeric listing of approved pharmaceutical companies and their respective labeler codes is located on the DHS or designated pharmacy vendor website. View or print numeric listing of approved pharmaceutical companies and their respective labeler codes. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with listed labeler codes.

Prescribers must obtain the latest information regarding prescription drug coverage from the DHS contracted Pharmacy Vendors website. View or print DHS contracted Pharmacy vendor contact information.

220.000 Benefit Limits 8-1-21

Benefit limits are the limits on the quantity of covered services Medicaid-eligible beneficiaries may receive. Medicaid-eligible beneficiaries are responsible for payment for services beyond the established benefit limits, unless the Division of Medical Services (DMS) authorizes an extension of a particular benefit.

If a service is denied for exceeding the benefit limit, and the Medicaid beneficiary had elected to receive the service by written informed consent prior to the delivery of the service, the Medicaid beneficiary is responsible for the payment, unless that service has been deemed not medically necessary.

Benefit extensions are considered after the service has been rendered and the provider has received a denial for "benefits exhausted." DMS considers requests for benefit extensions based on the medical necessity of the service. If a Medicaid provider chooses to file for an extension of benefits and is denied due to the service not being medically necessary, the beneficiary is not responsible for the payment. Once the extension of benefits request has been initiated on a specific service, the provider cannot abort the process before a final decision is rendered.

Please see Section 229.000 through Section 229.120 and Section 131.000 points A and C for benefit extension request procedures. DMS reviews extension of benefits requests for Home Health, personal care, diapers and medical supplies. DHS or its designated vendor reviews extension of benefits requests for physician, lab, radiology and machine tests, using form DMS-671. All personal care services for beneficiaries under age 21 are reviewed by the contracted Quality Improvement Organization (QIO). View or print contact information for DHS or its designated vendor regarding benefit limits.

224.200 Medicaid Utilization Management Program (MUMP) 8-1-21

The Medicaid Utilization Management Program (MUMP) determines covered lengths of stay in inpatient, general and rehabilitative hospitals, in state and out-of-state. The MUMP does not apply to lengths of stay in psychiatric facilities.

Length-of-stay determinations are made by DHS or the Quality Improvement Organization (QIO), under contract to the Arkansas Medicaid Program.

224.210 MUMP Applicability 8-1-21

224.310 Direct Admissions 8-1-21

224.320 Transfer Admissions 8-1-21

If a patient is transferred from one hospital to another, the receiving facility must contact DHS or its designated vendor within twenty-four (24) hours of admitting the patient to certify the inpatient stay. View or print contact information to obtain the DHS or designated vendor step-by-step process to request certification.

224.330 Retroactive Eligibility 8-1-21

224.340 Third Party and Medicare Primary Claims 8-1-21

224.350 Requests for Reconsideration 8-1-21

Reconsideration reviews of denied extensions may be requested by sending the medical record to DHS or its designated vendor. The hospital will be advised of the reconsideration decision by the next working day.

View or print contact information to obtain the DHS or designated vendor step-by-step process for reconsideration requests.

229.100 Extension of Benefits for Laboratory and X-Ray, Physician Office and Outpatient Hospital Services 8-1-21

229.110 Completion of Request Form DMS-671, "Request For Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services" 8-1-21

Requests for extension of benefits for Clinical Services (Physician's Visits), Outpatient Services (Hospital Outpatient visits), Laboratory Services (Lab Tests) and X-ray services (X-ray, Ultrasound, Electronic Monitoring - e.e.g.; e.k.g.; etc-), must be submitted to DHS or its designated vendor for consideration. View or print contact information to obtain the DHS or designated vendor step-by-step process to complete request. Consideration of requests for extension of benefits requires correct completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray (form DMS-671). View or print form DMS-671.

Instructions for accurate completion of form DMS-671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each Provider Manual.

229.130 Administrative Reconsideration of Extensions of Benefits Denial 8-1-21

229.210 Process for Requesting Extended Therapy Services 8-1-21

229.230 Extended Therapy Services Review Process 8-1-21

View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting extended therapy services.

229.240 Administrative Reconsideration 8-1-21

A request for administrative reconsideration of the denial of services must be in writing and sent to DHS or its designated vendor within thirty (30) calendar days of the denial. The request must include a copy of the denial letter and additional supporting documentation.

The deadline for receipt of the reconsideration request will be enforced pursuant to Sections 190.012 and 190.013 of the Arkansas Medicaid manual. A request received by DHS or its designated vendor within thirty-five (35) calendar days of a denial will be deemed timely.

251.110 Assistant Surgery 8-1-21

For medical payment to be made to an assistant surgeon, the physician who wishes to use an assistant surgeon must obtain prior authorization from the DHS or its designated vendor. Assistant surgeon services are reimbursed only when provided by a physician. See Section 261.000 of this manual for prior authorization instructions. This provision applies to all surgery.

251.220 Elective Abortions 8-1-21

Only medically necessary abortions are covered by Arkansas Medicaid. Federal regulations prohibit expenditures for abortions except when the life of the mother would be endangered if the fetus were carried to term or for victims of rape or incest, defined under Ark. § Code Ann. 5-14103 and § 5-22-202, as certified in writing by the woman's attending physician.

251.230 Cochlear Implant and External Sound Processor Coverage Policy 8-1-21

The Arkansas Medicaid Program provides coverage for cochlear implantation and the external sound processor for beneficiaries under age twenty-one (21) in the Child Health Services (EPSDT) Program. (See Section 261.120 for prior authorization requirements and Section 292.801 for billing protocol.)

251.300 Organ Transplants 8-1-21

251.303 Heart Transplants 8-1-21

251.304 Liver and Liver/Bowel Transplants 8-1-21

251.306 Lung Transplants 8-1-21

254.000 Enterra Therapy for Treatment of Gastroparesis 8-1-21

257.000 Tobacco Cessation Products and Counseling Services 8-1-21

Tobacco cessation products either prescribed or initiated through statewide pharmacist protocol are available without prior authorization (PA) to eligible Medicaid beneficiaries. Additional information can be found on the designated Pharmacy Vendor websiteor in the Prescription Drug Program Prior Authorization Criteria.

258.000 Hyperbaric Oxygen Therapy (HBOT) 8-1-21

Physicians may be reimbursed for attendance and supervision of hyperbaric oxygen therapy.

Hyperbaric oxygen therapy (HBOT) involves exposing the body to oxygen under pressure greater than one atmosphere. Such therapy is performed in specially constructed hyperbaric chambers holding one (1) or more patients; although oxygen may be administered in addition to the hyperbaric treatment. Patients should be assessed for contraindications such as sinus disease or claustrophobia prior to therapy. In some diagnoses, hyperbaric oxygen therapy (HBOT) is only an adjunct to standard surgical therapy. These indications are taken from "The Hyperbaric Oxygen Therapy Committee Report" (2003) of The Undersea and Hyperbaric Medical Society (Kensington, MD).

Hyperbaric oxygen therapy (HBOT) prior authorizations will be issued by DHS or its designated vendor. All hyperbaric oxygen therapy (HBOT) will require prior authorization, except in emergency cases such as for air embolism or carbon monoxide poisoning, in which case, post authorization will be allowed per protocol (See Section 261.100). Prior authorization will be for a specific number of treatments. Further treatments will require reapplication for a prior authorization. View or print contact information to obtain the DHS or designated vendor step-by-step process for HBOT prior authorization requests.

NOTE: When approved, only one authorization will be issued. The prior authorization and the number of approved HBOT treatments must be shared with the facility provider so that both the physician and the facility may be reimbursed for the number of approved HBOT sessions. Additionally, if more HBOT sessions are required, a new prior authorization must be requested and the above process followed. A new prior authorization will be assigned for any additional sessions approved. The prior authorization information between the physician and the facility shall be reciprocal if the facility acquires the prior authorization.

The following table provides the diagnosis requirements, description of the problem, and number of treatments.

Refer to Section 292.860 of this manual for billing instructions.

261.000 Obtaining Prior Authorization of Restricted Medical and Surgical Procedures 8-1-21

Certain medical and surgical procedures are covered only with prior authorization (PA). Refer to sections 261.100 through 261.220 for instructions on requesting PA.

261.100 Obtaining Prior Authorization 8-1-21

261.110 Post-Procedural Authorization Process for Beneficiaries Under Age 21 8-1-21

261.210 Prior Authorization of Ambulatory Infusion Device 8-1-21

261.220 Prior Approval of Transplant Procedures 8-1-21

272.830 Other Covered Transplants 8-1-21

Physician services relating to other covered transplant surgery procedures will be reimbursed at the lesser of negotiated rates or 80% of billed charges, subject to subsequent review to determine that only covered charges are reimbursed.

292.410 Abortion Procedure Codes 8-1-21

Abortion procedures performed when the life of the mother would be endangered if the fetus were carried to term require prior authorization from DHS or its designated vendor.

Abortion for pregnancy resulting from rape or incest must be prior authorized by the Division of Medical Services, Administrator, and Utilization Review.

The physician must request prior authorization for the abortion procedures and for anesthesia. Refer to Section 260.000 of this manual for prior authorization procedures. The physician is responsible for providing the required documentation to other providers (hospitals, anesthetist, etc.) for billing purposes.

All claims must be made on paper with attached documentation. A completed Certification Statement for Abortion (form DMS-2698 Rev. 8/04), patient history and physical are required for processing of claims.

Use the following procedure codes when billing for abortions.

Refer to Section 251.220 of this manual for policies and procedures regarding coverage of abortions and Sections 261.000, 261.100, 261.200, 261.260 for prior authorization instructions.

292.470 Fluoride Varnish Treatment 8-1-21

The American Dental Association (ADA) procedure code D1206 is covered by the Arkansas Medicaid Program. This code is payable for beneficiaries under the age of twenty-one (21). Topical fluoride varnish application benefit is covered every six (6) months plus (1) day for beneficiaries under age twenty-one (21).

A new specialty code, FC-Fluoride Certification will be tied to provider types 01, 03, 58 and 69. These providers must send proof of their fluoride varnish certification to Provider Enrollment before the specialty code will be added to their file in the MMIS. After the specialty code, FC-Fluoride Certification, is added to the provider's file, the provider will be able to bill for procedure code D1206, Topical Application of Fluoride Varnish.

Providers must check the Supplemental Eligibility Screen to verify that topical fluoride varnish benefit of two (2) per State Fiscal Year (SFY) has not been exhausted. If further treatment is needed due to severe periodontal disease, then the beneficiary must be referred to a Medicaid dental provider.

NOTE: This service is billed on form CMS-1500 with ADA procedure code D1206 (Topical application of fluoride varnish (prophylaxis not included) - child (ages 0-20). View a CMS-1500 sample form.

292.591 Molecular Pathology 8-1-21

Molecular Pathology procedure codes, including Healthcare Common Procedural Coding System Level II (HCPCS) procedure code G0452 requires prior authorization (PA). Providers must receive prior authorization before a claim for molecular pathology is filed for payment. Providers may request the PA from DHS or its designated vendor before or after the procedure is performed as long as it is acquired in time to receive approval and file a clean claim within the 365-day filing deadline. View or print contact information to obtain the DHS or designated vendor step-by-step process for prior authorization requests.

Molecular Pathology PA requests must be submitted by the performing provider with submission of a completed Arkansas Medicaid Request for Molecular Pathology Laboratory services (Form DMS-841) and all pertinent clinical documentation needed to justify the procedure.

Reconsideration of a denied request is allowed if new or additional information is received within thirty (30) days of the initial denial. A copy of the DMS-841 is located in Section V of this provider manual. View or print form DMS-841. Do not complete DMS-841 unless you are submitting a Molecular Pathology Prior Authorization request. Molecular Pathology procedure codes must be submitted on a red line CMS-1500 claim form with the Prior Authorization number listed on the claim form and the itemized invoice attached which supports the charges for the test billed.

Use Healthcare Common Procedural Coding System Level II (HCPCS) procedure code G0452 for coding the Interpretation and Report of 2013 Molecular Pathology codes that allow separate Interpretation and Report. The prior authorization request for G0452 must be submitted with the Arkansas Medicaid Request for Molecular Pathology Laboratory Services (Form DMS-841). Prior authorization for G0452 must be obtained at the same time as the prior authorization for the CPT Molecular Pathology code. The prior authorization request for G0452 must include the CPT Molecular Pathology procedure code for which the Interpretation and Report is to be provided. G0452 must be billed on a red line CMS-1500 paper claim form with CPT Molecular Pathology code(s) specified for which the Interpretation and Report was performed. The claim form should list the prior authorization number. The invoice must be attached that reflects the cost to the provider for performing the interpretation and report of the test.

See Section 262.000 for additional information on Molecular Pathology procedure codes.

292.672 Method 2 - "Itemized Billing" 8-1-21

Use this method only when either of the following conditions exists:

292.900 Tobacco Cessation Counseling Services 8-1-21

201.600 Podiatrist's Role in the Pharmacy Program 8-1-21

PRESCRIPTION DRUG INFORMATION

Medicaid covers prescription drugs in accordance with policies and regulations set forth in this section and pursuant to orders (prescriptions) from authorized prescribers in relation to their specialty of practice. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. A numeric listing of approved pharmaceutical companies and their respective labeler codes is located on the DHS or designated pharmacy vendor website. View or print numeric listing of approved pharmaceutical companies and their respective labeler codes. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with listed labeler codes.

The latest information regarding prescription drug coverage is available from DHS or its designated Medicaid Pharmacy vendor. View or print contact information for the DHS contracted Pharmacy Vendor.

214.000 Benefit Limits 8-1-21

Medicaid-eligible patients are responsible for payment for services beyond the established benefit limits, unless DHS or its designated vendor authorizes an extension of a particular benefit. If a Medicaid-eligible patient elects to receive a service for which a benefit extension has been denied or is subsequently denied, the patient is responsible for payment. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting extension of benefits.

215.100 Procedure for Obtaining Extension of Benefits for Podiatry Services 8-1-21

215.115 Extension of Benefits Review Process 8-1-21

View or print contact information to obtain the DHS or designated vendor step-by-step process for extension of benefits review.

220.000 PRIOR AUTHORIZATION

There are certain surgical procedures and medical services and procedures that are not reimbursable without prior authorization, either because of federal requirements or because of the nature of the service.

DHS or its designated vendor performs prior authorizations for several medical or surgical procedures. Certain procedures are restricted to the outpatient setting unless prior authorized for inpatient services. Other services may only be billed when performed in a nursing home or skilled nursing facility setting. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting prior authorization.

Section 242.120 contains the list of all procedure codes that require prior authorization.

221.000 Prior Authorization 8-1-21

Prior authorization determinations are made by utilizing established medical or administrative criteria combined with the professional judgment of physician advisors. Payment of services is made to participating providers in accordance with federal regulations.

221.100 Procedure for Requesting Prior Authorization 8-1-21

It is the responsibility of the podiatrist to initiate the prior authorization request. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting prior authorization.

CPT codes that require prior authorization are located in Section 242.120 of this manual.

221.200 Approvals and Denials of Prior Authorization Requests 8-1-21

221.300 Post-Authorization 8-1-21

Post-authorization will be granted only for emergency procedures or retroactively eligible beneficiaries. Requests for emergency procedures must be requested on the first working day after the procedure has been performed. In cases of retroactive eligibility, DHS or its designated vendor must be contacted for post-authorization within sixty (60) days of the authorization date. View or print contact information to obtain the DHS or designated vendor step-by-step process for post-authorization.

214.100 Extension of Benefits for X-Ray Services 8-1-21

214.110 Completion of Form DMS-671, "Request For Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services" 8-1-21

Requests for extension of benefits for Clinical Services (Physician's Visits), Outpatient Services (Hospital Outpatient visits), Laboratory Services (Lab Tests) and X-ray services (X-ray, Ultrasound, Electronic Monitoring - e.e.g.; e.k.g.; etc-), must be submitted to DHS or its designated vendor. View or print DHS or its designated vendor contact information for extension of benefits for how to obtain information regarding submission processes. AFMC for consideration. Consideration of requests for extension of benefits requires correct completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray (form DMS-671). View or print form DMS-671.

Instructions for accurate completion of form DMS- 671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each Provider Manual.

211.300 Prosthetics Service Provision 8-1-21

At least once every six (6) months, the prosthetics provider must receive a prescription for prosthetics services from either the beneficiary's primary care physician or advanced practice registered nurse within the scope of practice and, when applicable:

211.800 Electronic Filing of Extension of Benefits 8-1-21

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 three (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.

212.201 (DME) Apnea Monitors for Infants Under Age 1 8-1-21

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.

For the initial certification, the prescribing physician must sign form DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and 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 in consultation with a neonatologist or pulmonologist.

As necessary, the primary care physician's (PCP's) name and provider number must also be indicated on DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. The PCP's signature is not required on the initial certification but he or she must sign all re-certifications.

A prior authorization request for an apnea monitor must be submitted to DHS or its designated vendor on form DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. View or print form DMS-679 and instructions for completion. View or print contact information for how to obtain information regarding submission processes.

Prior authorization is not required for the initial sixty-day period of use of the monitor. If the apnea monitor is needed longer than an initial sixty-day period, prior authorization is required.

A new prescription, documentation of compliance during the initial sixty-day period and proof of medical necessity for the continuation of monitoring are required.

Documentation of compliance and the download monitor report must accompany the request for continued use of the apnea monitor following the initial sixty-day time period.

The following criteria, established by the American Academy of Pediatrics, are to be used to evaluate the need for an apnea monitor after the initial sixty-day period:

212.202 (DME) Augmentative Communication Device (ACD), All Ages 8-1-21

The augmentative communication device (ACD) is covered for beneficiaries of all ages. Coverage for beneficiaries under twenty-one (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 twenty-one (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 DMS-679A. View or print form DMS-679A.

The ACD is also covered for Medicaid beneficiaries twenty-one (21) years old and older. Prior authorization is required on the device and on repairs of the device. For beneficiaries who are age twenty-one (21) and above, a $7,500.00 lifetime benefit without benefit extensions applies.

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.

Form DMS-679A, 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. View or print contact information for how to obtain information regarding submission processes for augmentative communication device.

The form should be accompanied by:

212.203 Cochlear Implants for Beneficiaries Under Age 21 8-1-21

Cochlear implants are covered through the Arkansas Medicaid Physician or Prosthetics Programs for eligible Medicaid beneficiaries under the age of twenty-one (21) years through the Child Health Services (EPSDT) program when prescribed by a physician.

The replacements of lost, stolen or damaged external components (not covered under the manufacturer's warranty) are covered when prior authorized by Arkansas Medicaid.

Reimbursements for manufacturer's upgrades will not be made. An upgrade of a speech processor to achieve aesthetic improvement, such as smaller profile components, or a switch from a body-worn, external sound processor to a behind-the-ear (BTE) model or technological advances in hardware are not considered medically necessary and will not be approved.

212.204 (DME) Electronic Blood Pressure Monitor and Cuff for Beneficiaries of All Ages 8-1-21

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 (1) disposable blood pressure cuff each month.

Prior authorization is required for the use of this item. Providers may request prior authorization by submitting form DMS-679A, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to DHS or its designated vendor. View or print form DMS-679A and instructions for completion. View or print contact information for how to submit the request.

212.205 (DME) Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply Kit for Beneficiaries Under Age 21 8-1-21

The request for an enteral nutrition pump is covered on a case-by-case basis for beneficiaries under age twenty-one (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 DHS or its designated vendor using form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print contact information for how to submit the request. View or print form DMS-679A 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 one (1) day equaling one (1) unit of service. A maximum of one (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 DMS-679A and instructions for completion.

Requests for prior authorization for enteral pump repairs must be submitted to DHS or its designated vendor. Form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be used to request prior authorization. View or print contact information for how to submit the request. View or print form DMS-679A and instructions for completion.

212.207 (DME) Insulin Pump and Supplies, All Ages 8-1-21

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 covered through the prescription drug program.

The following criteria will be utilized in evaluating the need for the insulin pump:

212.212 (DME) Specialized Rehabilitative Equipment, All Ages 8-1-21

Arkansas Medicaid covers specialized rehabilitative equipment for Medicaid-eligible beneficiaries of all ages.

Some items of specialized equipment require prior authorization from DHS or its designated vendor. View or print form DMS-679A and instructions for completion. View or print contact information for how to submit the request.

212.213 (DME) Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult 8-1-21

Arkansas Medicaid covers specialized wheelchairs and wheelchair seating systems for individuals age two (2) through adulthood.

Some items of specialized equipment require prior authorization from DHS or its designated vendor. View or print form DMS-679 and instructions for completion. View or print contact information for how to submit the request.

212.600 Orthotic Appliances and Prosthetic Devices, All Ages 8-1-21

212.700 Oxygen and Oxygen Supplies, All Ages 8-1-21

A prescription for oxygen must be accompanied by a current arterial blood gas (ABG) laboratory report from a certified laboratory or the beneficiary's attending physician. A current laboratory report is defined as one performed within a maximum of thirty (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 beneficiary (e.g., two liters per minute, ten (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:

221.100 Request for Prior Authorization 8-1-21

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. View or print contact information for how to submit the request.

221.300 Approvals of Prior Authorization 8-1-21

236.000 Reimbursement for Repair of the Enteral Nutrition Pump 8-1-21

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 submitted to DHS or its designated vendor. View or print contact information for how to submit the request. Requests must be made on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. (View or print form DMS-679A 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 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.

242.122 Jobst Stocking for Beneficiaries of All Ages 8-1-21

The gradient compression stocking (Jobst) is payable for beneficiaries of all ages. However, before supplying the item, the Jobst stocking must be prior authorized by DHS or its designated vendor. View or print contact information for how to submit the request. Documentation accompanying form DMS-679A must indicate that the beneficiary has severe varicose veins with edema, or a venous stasis 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. View or print form DMS-679A and instructions for completion.

242.152 Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply Kit 8-1-21

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under twenty-one (21) years of age. When a second modifier is listed, that modifier must be used in conjunction with EP.

The procedure codes require prior authorization from DHS or its designated vendor. View or print contact information for how to submit the request.

Modifiers in this section are indicated by the headings M1 and M2. 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.

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.

242.195 Repairs of Specialized Wheelchairs and Wheelchair Systems 8-1-21

213.010 Inpatient Hospital Services Benefit Limit 8-1-21

213.100 Medicaid Utilization Management Program (MUMP) 8-1-21

The Medicaid Utilization Management Program (MUMP) determines covered inpatient lengths of stay in general and rehabilitative hospitals, in state and out-of-state. The MUMP does not apply to lengths of stay in psychiatric facilities.

Length-of-stay determinations are made by the Quality Improvement Organization (QIO), under contract to the Arkansas Medicaid Program.

213.110 MUMP Applicability 8-1-21

213.150 Retroactive Eligibility 8-1-21

213.160 Third Party and Medicare Primary Claims 8-1-21

213.170 Requests for Reconsideration 8-1-21

Reconsideration reviews of denied extensions may be expedited by submitting the medical record to DHS or its designated vendor. View or print contact information for how to submit the request.

215.120 Benefit Extension Requests 8-1-21

215.123 Provider Notification of Benefit Extension Determinations 8-1-21

A benefit extension approval or denial-or request for additional information-will be returned to the provider within thirty (30) calendar days.

216.000 Retrospective Review of Occupational, Physical and Speech Therapy Services for Beneficiaries Under Age 21 8-1-21

DHS or its designated vendor performs retrospective reviews of medical records to determine the medical necessity of services paid for by Medicaid. View or print contact information for retrospective reviews.

Specific guidelines have been developed for retrospective review of occupational, physical and speech-language therapy services furnished to Medicaid beneficiaries under the age of twenty-one (21). Those guidelines are included in this manual to assist providers in determining and documenting medical necessity. The guidelines are found in Sections 216.100 through 216.108.

216.112 Process for Requesting Extended Therapy Services for Beneficiaries Under Age 21 8-1-21

216.114 Extended Therapy Services Review Process 8-1-21

View or print contact information to obtain the DHS or designated vendor step-by-step process for an extended therapy services review.

217.100 Coverage Limitation-Medicaid Utilization Management Program 8-1-21

The Medicaid Utilization Management Program (MUMP) is designed to manage the appropriateness and duration of RSPD services. The MUMP procedures apply to all RSPD providers.

Length-of-stay determinations are performed by the Quality Improvement Organization (QIO), under contract to the Arkansas Medicaid Program.

217.110 MUMP Applicability 8-1-21

Medicaid beneficiaries are allowed up to four (4) days of RSPD services when the admission criteria (refer to Sections 213.000 through 213.300) are met. If a patient is not discharged before or during the fifth day of the residential stay, DHS or its designated vendor must certify any additional days.

When a patient is transferred from one RSPD facility to another, the stay must be certified by DHS or its designated vendor from the first day of transfer. (See Transfer Admissions, Section 217.132.) View or print contact information to obtain the DHS or designated vendor step-by-step process for submitting the request.

217.131 Extension of RSPD Admissions 8-1-21

217.132 Transfer Admissions 8-1-21

If a patient is transferred from one RSPD facility to another, the receiving facility must contact DHS or its designated vendor within twenty-four (24) hours to certify the residential stay. View or print the contact information to obtain the DHS or designated vendor step-by-step process for submitting the request.

217.133 Retroactive Medicaid Eligibility 8-1-21

217.134 Third Party and Medicare Claims 8-1-21

If a provider has not requested MUMP certification of an extension of days because there is apparent coverage by private insurance or Medicare Part A, but the other payer has denied the claim for non-covered service, lost eligibility, benefits exhausted, etc., post-certification of days beyond the first four (4) days may be obtained.) View or print contact information to obtain the DHS or designated vendor step-by-step process for submitting the request

262.300 Billing Instructions-Paper Only 8-1-21

Medicaid does not supply providers with Uniform Billing claim forms. Numerous venders sell CMS-1450 (UB-04 forms.) View a sample CMS-1450 (UB-04) claim form.

Complete Arkansas Medicaid program claims in accordance with the National Uniform Billing Committee UB-04 data element specifications and Arkansas Medicaid's billing instructions, requirements, and regulations for claim form CMS-1450.

The National Uniform Billing Committee (NUBC) is a voluntary committee whose work is coordinated by the American Hospital Association (AHA) and is the official source of information regarding CMS-1450 (UB-04.) View or print NUBC contact information.

The committee develops, maintains, and distributes to its subscribers the UB-04 Data Element Specifications Manual and periodic updates. The NUBC is also a vendor of CMS-1450 (UB-04) claim forms.

Following are Arkansas Medicaid's instructions for completing, in conjunction with the UB-04 Data Element Specifications Manual (UB-04 Manual), a CMS-1450 (UB-04) claim form.

Forward the original of the completed form to the Fiscal Agent's Claims Department. View or print DHS or its designated Fiscal Agent's contact information. One (1) copy of the claim form should be retained for your records.

NOTE: A provider furnishing services without verifying beneficiary eligibility for each date of service does so at the risk of not being reimbursed for the services. The provider is strongly encouraged to print the eligibility verification and retain it until payment is received.

218.310 Benefit Extension Requests 8-1-21

242.000 Prior Authorization and Documentation Requirements for Medicaid Eligible Beneficiaries Under Age 21 8-1-21

DHS or its designated vendor must approve all requests for prior authorization for targeted case management services for Medicaid eligible beneficiaries under age twenty-one (21). View or print contact information to obtain instructions for submitting the request.

The following information must be submitted for Child Health Services (EPSDT) beneficiaries and for DDS eligible beneficiaries under the age of twenty-one (21):

242.100 Prior Authorization Request for Targeted Case Management for Medicaid Eligible Beneficiaries Under Age 21 8-1-21

Requests for prior authorization must be submitted using the Request for Targeted Case Management Prior Authorization for Beneficiaries Under Age 21 Form (DMS-601). View or print form DMS-601. The documentation submitted with the prior authorization request must support the medical necessity of the requested services.

A medical necessity determination will be made within fifteen (15) working days of receipt of a completed prior authorization request. For prior authorization requests meeting the medical necessity requirements, an authorization number designation, the length of services, procedure codes and units approved for the requesting provider will be issued. For denied requests, a letter containing case-specific rationale that explains why the request was not approved will be sent to the requesting provider and to the Medicaid beneficiary.

281.100 EIDT/ADDT Transportation Survey 8-1-21

EIDT and ADDT transportation providers are required to prepare and submit an annual EIDT/ADDT Survey (View or print EIDT/ADDT Transportation Survey DMS-632)and other applicable information concerning the survey to the Arkansas Department of Human Services Division of Medical Services, Provider Reimbursement Unit. View or print the Arkansas Department of Human Services Division of Medical Services, Provider Reimbursement Unit contact information.

The survey information will be reported for the provider's fiscal period. The survey must be submitted within five (5) months after the close of the provider's fiscal year end. Providers with financial reporting periods of less than six (6) months are not required to submit a survey. However, if no survey is required, the provider must notify the Division of Medical Services (DMS) in writing why the survey is not being submitted. Failure to submit the completed survey or failure to submit a written explanation of a reporting period of less than six (6) months within the prescribed period, except as expressly extended by the State Medicaid agency, may result in the suspension of reimbursement until DMS receives this information.

Survey information requested includes direct and indirect/overhead costs, revenues and client mileage information associated with and applicable to the EIDT or ADDT Transportation Program. No other program costs, revenues or mileage information is to be included on the survey. If the provider provides transportation services for programs other than EIDT or ADDT programs, please remove the other program costs, revenues and mileage information before completing the survey and submit a narrative describing how these other transportation program amounts were calculated and removed. All cost and revenue amounts are to be reported using the accrual method of accounting and will be reported in whole dollar amounts, no cents.

Providers must also submit with the survey a written general description of what costs are included with indirect/overhead costs and how these costs were identified, calculated and allocated to the EIDT or ADDT transportation program.

Providers are required to maintain adequate financial records, mileage data and rider data for proper documentation and support of the cost and statistical information reported on the annual survey. These records must be retained for a period of five (5) years after submission of the survey. The surveys, supporting documentation and provider narratives are subject to on-site review and inspection by DHS/DMS personnel.

EIDT and ADDT providers may order copies of Form DMS-632 on the Medicaid Form Request. Requests may be forwarded to the DHS or designated Fiscal Agent's Provider Assistance Center. View or print the DHS or designated Fiscal Agent's contact information.

221.000 Prior Authorization (PA) 8-1-21

Reimbursement for ventilator equipment must have prior approval by DHS or its designated vendor. View or print contact information to obtain instructions for submitting the request.

222.000 Request for Prior Authorization 8-1-21

A request for prior authorization must originate with the provider of ventilator equipment. The provider is responsible for obtaining the required medical information and necessary prescription information needed for completion of form DMS-679. This form must be signed and dated by the physician. View or print form DMS-679 and instructions for completion.

Providers must specify the brand name/model of the ventilator on the prior authorization request.

The documentation submitted with the prior authorization request must support the medical necessity of the requested ventilator. If necessary additional information (i.e., original prescription, records from the hospitalization initiating the need for ventilator, etc.) shall be requested from the provider.

A prior authorization of ventilator equipment services does not guarantee payment.

Providers must note the date the ventilator is no longer in daily use.

222.100 Approvals of Prior Authorization 8-1-21

When a prior authorization (PA) request is approved, a prior authorization control number will be assigned and returned to the requesting provider.

Prior authorization approvals are authorized for a maximum of six (6) months (180 days) or for the life of the prescription, whichever is shorter. A new request must be made for services needed for a longer period of time.

The effective date of the pa will be the date the beneficiary begins using the equipment or the day following the last day of the previous prior authorization approval.

Within thirty (30) working days before the end of an authorization for ventilator equipment, the provider must obtain a new prescription and submit a new Medical Equipment Request for Prior Authorization and Prescription (form DMS-679) signed by the prescribing physician.

PA for ventilator equipment does not guarantee payment. The beneficiary must be Medicaid-eligible on the dates of service and must have available benefits. The provider must follow all applicable billing procedures.

216.200 Procedure for Obtaining Extension of Benefits for Medical Services Provided by an Optometrist 8-1-21

216.210 Completion of Form DMS-671, "Request For Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services" 8-1-21

Requests for extension of benefits for Clinical Services (Physician's Visits) Outpatient Services (Hospital Outpatient visits), Laboratory Services (Lab Tests) and X-ray services (X-ray, Ultrasound, Electronic Monitoring-EEG, EKG, etc.) must be submitted to DHS or its designated vendor for consideration. View or print contact information to obtain instructions for submitting the request. Requests for extension of benefits requires correct completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray (form DMS-671). View or print DMS-671 form.

Instructions for accurate competition of form DMS-671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each provider manual.

216.300 Prescription Drugs 8-1-21

PRESCRIPTION DRUG INFORMATION

Act 186 of 1997 authorizes optometrists to prescribe and administer both oral and topical drugs for the diagnosis and treatment only of conditions of the eye, lids, adnexa or visual system, except for those drugs listed in Schedules I and II of the Uniform Controlled Substance Act. They can also prescribe and administer epinephrine, Benadryl® or other comparable medication for the emergency treatment of anaphylaxis or anaphylactic reactions.

Medicaid covers prescription drugs in accordance with policies and regulations set forth in this section and pursuant to orders (prescriptions) from authorized prescribers. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. A numeric listing of approved pharmaceutical companies and their respective vendors is located on the DHS or designated Pharmacy vendor website. View or print numeric listing of approved pharmaceutical companies and their respective labeler codes. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with listed labeler codes.

For prescription drug prior authorization concerns or the latest information regarding prescription drug coverage, providers may visit the Prescription Drug PA Help Desk.

For questions regarding the Evidence-Based Prescription Drug Program or to request an override for non-preferred drugs, prescribers may contact the DHS Contracted Pharmacy Vendor Help Desk.

221.100 Extension of Benefits Review Process 8-1-21

Extension of Benefits must be submitted to DHS or its designated vendor for review. View or print contact information to obtain a step-by-step outline for the extension process.

242.430 Special Processing Procedures 8-1-21

The CMS-1500 claim form must be used by the ophthalmologists or optometrists when billing the Medicaid Program for non-prescription services. Submit the completed claim form to the Arkansas Medicaid fiscal agent.

If prescription services are required and are within the allowable limits outlined in Section 213.200, the provider must complete the prescription form provided by the optical contractor. Visual Care providers who submit claims electronically must submit a copy of the eligibility verification for the date on which the service is being provided along with the prescription form to the optical contractor for processing. The printout will provide verification of the beneficiary's eligibility, last visual exam date and last optical prescription date. (A photocopy of the beneficiary's plastic identification card will not be accepted by the optical contractor.) The prescription form and the eligibility verification can be sent to the optical contractor. View or print the DHS Designated Optical Contractor contact information.

If the copy of the eligibility on the date of service is not verified, and/or the benefit has been exhausted, the optical contractor will not fill the prescription and will return the claim to the physician.

101.300 Obtaining Provider Manuals 8-1-21

All provider manuals, manual updates, notices of rule making, official notices and RAs are available for downloading, without charge, from the Arkansas Medicaid website.

Enrolled providers may purchase extra paper copies of a manual through the fiscal agent. See information below regarding purchasing copies. Persons, entities and organizations that are not enrolled providers may purchase a paper copy of a provider manual through the fiscal agent.

The cost for a printed copy of an Arkansas Medicaid provider manual is $125.00.

Send orders for printed manuals to the Arkansas Medicaid Fiscal Agent, Information Library Unit. Include with your order a check made to the Fiscal Agent for the appropriate amount. View or print the manual order contact information.

110.200 Provider Relations and Claims Processing Contractor 8-1-21

Provider assistance and education and the processing of claims for the Medicaid program are performed by an independent contractor.

The Arkansas Medicaid Fiscal Agent has a staff of claims representatives available to assist with any needs concerning claims.

The Arkansas Medicaid Fiscal Agent maintains a Provider Assistance Center (PAC) to assist Arkansas Medicaid providers.

The Arkansas Medicaid fiscal agent has a full-time staff of Provider Representatives available for consultation regarding billing problems and technical assistance that cannot be resolved through the Provider Assistance Center. Provider Representatives are available to visit providers' offices to provide training on billing and on-site technical assistance. To find your Provider Representative to schedule a visit, view the DHS or designated vendor's Outreach Specialistspage.

301.240 Prior Authorization Request 8-1-21

Providers can review instructions for Prior Authorization Requests in the Section II of their program's provider manual.

Some prior authorizations are processed by other Medicaid contractors:

314.131 The Adjustment Transaction 8-1-21

The Claim Adjustments report has two parts. The first includes the adjustment transaction header elements. In this section, the Arkansas Medicaid fiscal agent identifies the adjustment transaction with an internal control number (ICN). Adjustment ICNs are formatted in the same way as claim numbers; the first two digits of an adjusted claim ICN indicate the type of adjustment:

Displayed to the right of the ICN are the provider's patient control number or medical record number from the original claim, the claim beginning and ending dates of service and the original billed amount. Keep in mind that the Arkansas Medicaid fiscal agent adjusts the entire claim, even if only one detail paid in error, so the total billed amount shown here is the total billed amount of the entire claim being adjusted. Other withheld or credited amounts that impact the paid amount are listed and can include insurance, spenddown, copay (coinsurance) and deductible amounts. The Adjustment EOB code entered when the claim was adjusted indicates the reason for initiating the claim adjustment.

The second part of the adjustment transaction displays the claim details and the adjudication of the reprocessed claim. Detail EOBs for each procedure code are shown.

Additional payment, overpayment to be withheld, refund amount applied as well as total claim adjustments are shown at the bottom of the Claim Adjustments report. The actual withholding of the original paid amount does not occur in the Claim Adjustments report; it occurs in the Financial Transactions report of the RA. Adjustments are listed in the Accounts Receivable section, with the appropriate amounts displayed under the field headings "A / R (Action/Reason) Number," "Setup Date,": "Original Amount," "Recoupment Amount to Date," "Balance," "Reason Code," "Adjustment ICN," "Previous ICN," and "Amount Recouped in Current Cycle." (See the discussion of Financial Transactions in Section 314.170.)

Finally, the total of all adjusted amounts paid or withheld from the remittance are displayed in the Summary report of the RA under the field header Claims Data "Claim Adjustments" and Earnings Data "Payments: Claim Specific: Current Cycle."

332.100 Medicare-Medicaid Crossover Claim Filing Procedures 8-1-21

If medical services are provided to a patient who is entitled to and is enrolled with coverage within the original Medicare plan under the Social Security Act and also to Medicaid benefits, it is necessary to file a claim only with the original Medicare plan. The claim must be filed according to Medicare's instructions and sent to the Medicare intermediary. The claim should automatically cross to Medicaid if the provider is properly enrolled with Arkansas Medicaid and indicates the beneficiary's dual eligibility on the Medicare claim form. According to the terms of the Medicaid provider contract, a provider must "accept Medicare assignment under Title XVIII (Medicare) in order to receive payment under Title XIX (Medicaid) for any appropriate deductible or coinsurance which may be due and payable under Title XIX (Medicaid)." See Section 142.700 for further information regarding Medicare/Medicaid mandatory acceptance of assignment for providers.

When the original Medicare plan intermediary completes the processing of the claim, the payment information is automatically crossed to Medicare's Coordination of Benefits Agreement (COBA) process and from there crossed to Arkansas Medicaid and the claim is processed in the next weekend cycle for Medicaid payment of applicable coinsurance and deductible. The transaction will usually appear on the provider's Medicaid RA within four (4) to six (6) weeks of payment by Medicare. If it does not appear within that time, payment should be requested according to the instructions below.

Claims for Medicare beneficiaries entitled under the Railroad Retirement Act do not cross to Medicaid. The provider of services must request payment of co-insurance and deductible amounts through Medicaid according to the instructions below, after Railroad Retirement Act Medicare pays the claim.

Medicare Advantage/Medigap Plans (like HMOs and PPOs) are health plan options that are available to beneficiaries, approved by Medicare, but run by private companies. These companies bill Medicare and pay directly through the private company for benefits that are a part of the Medicare Program, as well as offering enhanced coverage provisions to enrollees. Since these claims are paid through private companies and not through the original Medicare plan directly, these claims do not automatically cross to Medicaid; and the provider must request payment of Medicare covered services co-insurance and deductible amounts through Medicaid according to the below instructions after the Medicare Advantage/Medigap plan pays the claim.

When a provider learns of a patient's Medicaid eligibility only after filing a claim to Medicare, the instructions below should be followed after Medicare pays the claim.

Instructions: The Arkansas Medicaid fiscal agent provides software and web-based technology with which to electronically bill Medicaid for crossover claims that do not cross to Medicaid.

Additional information regarding electronic billing can be located in this Sections 301.000 through 301.200. Providers are strongly encouraged to submit claims electronically or through the Arkansas Medicaid website. Front-end processing of electronically and web-based submitted claims ensures prompt adjudication and facilitates reimbursement.

Providers without electronic billing capability must mail the appropriate National Standard Claim Form (CMS-1500 or CMS-1450) to the Fiscal Agent. Along with the National Standard Claim Form, providers must submit attachment DMS-600. (View or print attachment DMS-600.) Providers must also submit the Medicare Explanation of Benefits (EOMB). Claims must be submitted in the following order: