Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 29 - Division of Medical Services
Rule 016.29.22-003 - Medicaid Limits on Lab/Radiology and SPA 2022-0003

A. Both diagnostic laboratory and radiology/other services in all settings, including ASCs, are subject to a benefit limit.

B. Magnetic resonance imaging (MRI) services are exempt from the radiology/other services benefit limit per SFY.

C. Individuals under twenty-one (21) years of age are not subject to the diagnostic laboratory services benefit limit or to the radiology/other services benefit limit, except for the limitations on fetal echography (ultrasound) and fetal non-stress tests.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Requests to extend benefits for outpatient visits, diagnostic laboratory services, and radiology/other services must be submitted to DHS or its designated vendor.

View or print contact information for how to obtain information regarding submission processes.

Benefit extension requests are considered only after a claim has been filed and denied because the benefit is exhausted.

C. Submit with the request a copy of the Medical Assistance Remittance and Status Report reflecting the claim's denial for exhausted benefits. Do not send a claim.

D. Additional information will be requested as needed to process a benefit extension request. Failures to provide requested additional information within the specified timeline will result in technical denials. Reconsiderations for technical denials are not available.

E. Benefit extension requests must be received within ninety (90) calendar days of the date of the benefits-exhausted denial.

F. Correspondence regarding benefit extension requests and requests for reconsideration of denied benefit extension requests does not constitute documentation or proof of timely claim filing.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Benefit extension requests will be considered only when the provider has correctly completed all applicable fields of the "Request for Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services" Form DMS-671. View or print form DMS-671.

C. The date of the request and the signature of the provider's authorized representative are required on the form. Stamped or electronic signatures are accepted.

D. Dates of service must be listed in chronological order on Form DMS-671. When requesting benefit extensions for more than four (4) procedures, use a separate form for each set of procedures.

E. Enter a valid ICD diagnosis code and a brief narrative description of the diagnosis.

F. Enter a valid procedure code or revenue code, modifier(s) when applicable and a brief narrative description of the procedure.

G. Enter the number of units of service requested under the extension.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Records supporting the medical necessity of extended benefits must be submitted with benefit extension requests.

C. Clinical records must:

D. Laboratory and radiology/other reports must include:

A. Chiropractic services must be administered by a licensed chiropractor, meeting minimum standards promulgated by the Secretary of Health and Human Services under Title XVIII of the Social Security Act. Manipulation of the spine for the treatment of subluxation is the only chiropractic service covered by Medicaid.

B. Benefits.

C. For beneficiaries who are eligible for Medicare and Medicaid, see Section I of this manual for additional coinsurance and deductible information. See Section III for instructions on filing joint Medicare/Medicaid claims.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Requests for extension of benefits for clinical services (physician's visits), outpatient services (hospital outpatient visits), laboratory services (diagnostic laboratory tests), and radiology/other services 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, Diagnostic Laboratory, and Radiology/Other Services: form (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 Vof each Provider Manual.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. To request extension of benefits for any services with benefit limits, all applicable records that support the medical necessity of extended benefits are required.

C. Documentation requirements include the following:

A. *Authorized procedure codes must be used when filing claims for chiropractic X-rays.

B. Chiropractic X-rays are limited to two (2) per State Fiscal Year (SFY: July 1 through June 30). This service counts against the five-hundred-dollar per SFY (per beneficiary) radiology/other services benefit limit.

C. Radiology/other services include without limitation diagnostic X-rays, ultrasounds, and electronic monitoring/machine tests, such as electrocardiograms (ECG or EKG).

A. Diagnostic laboratory services benefits are limited to five hundred dollars ($500) per State Fiscal Year (SFY: July 1 through June 30), and radiology/other services benefits are limited to five hundred dollars ($500) per SFY.

B. Radiology/other services include without limitation diagnostic X-rays, ultrasounds, and electronic monitoring/machine tests, such as electrocardiograms (ECG or EKG).

C. Diagnostic laboratory services and radiology/other services defined as Essential Health Benefits by the U.S. Preventive Services Task Force (USPSTF) are exempt from counting toward either of the two new annual caps.

View or print the essential health benefit procedure codes.

A. Medicaid established maximum amounts (benefit limits) for outpatient diagnostic laboratory and for outpatient radiology/other services for clients who are twenty-one (21) years of age or older.

B. There are no diagnostic laboratory services benefit limits or radiology/other services benefit limits for clients under twenty-one (21) years of age, except for the limitations on fetal echography (ultrasound) and fetal non-stress tests.

C. There is no benefit limit on professional components of diagnostic laboratory or radiology/other services for hospital inpatient treatment.

D. There is no benefit limit on diagnostic laboratory services related to family planning. (See Section 272.431 for the family-planning-related clinical laboratory procedures.)

E. There is no benefit limit on diagnostic laboratory or radiology/other services performed in conjunction with emergency services in an emergency department of a hospital.

A. A Certified Nurse-Midwife (CNM), referring a Medicaid client for diagnostic laboratory services or radiology/other services must specify a diagnosis code (ICD coding) for each test ordered and include pertinent supplemental diagnoses supporting the need for the test(s) in the order.

B. The following benefit limits apply:

A. The Medicaid Program's diagnostic laboratory and radiology/other services have benefit limits that apply to outpatient services.

B. Certified Nurse Midwife (CNM) requests for extension of benefits for clinical, outpatient, diagnostic laboratory, and radiology/other services must be submitted to DHS or its designated vendor.

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

C. A request for extension of benefits must be received within ninety (90) calendar days of the date of the benefits-exhausted denial.

D. Additional information will be requested, as needed, to process a benefit extension request. Reconsiderations (of additionally requested information) are not available. Failure to provide requested information within the specified time will result in a technical denial.

E. Correspondence regarding benefit extension requests and requests for reconsideration of denied benefit extension requests do not constitute documentation or proof of timely claim filing.

A. The Medicaid Program's diagnostic laboratory and radiology/other services have benefit limits that apply to outpatient services.

B. Requests for extension of benefits for clinical services (physician's visits), outpatient services (hospital outpatient visits), diagnostic laboratory services (laboratory tests) and radiology/other services 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 extension of benefits.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. To request an extension of benefits for any services with benefit limits, all applicable records (that support the medical necessity of extended benefits) are required.

C. Documentation requirements are as follows.

A. Benefit extension requests will be considered only when the provider has correctly completed all applicable fields of the "Request for Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services" form (Form DMS-671). View or print Form DMS-671.

B. The date of the request, and the signature of the provider's authorized representative, are required on the form. Stamped and electronic signatures are accepted.

C. Dates of service must be listed in chronological order on Form DMS-671. When requesting benefit extensions for more than four (4) encounters, use a separate form for each set of encounters.

D. Enter a valid ICD diagnosis code and brief narrative description of the diagnosis.

E. Enter the procedure code, modifier(s) (when applicable) and a brief narrative description of the procedure.

F. Enter the number of units (encounters) requested under the extension.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Records supporting the medical necessity of extended benefits must be submitted with benefit extension requests and requests for reconsideration of denied benefit extension requests.

C. Clinical records must:

D. Diagnostic laboratory and radiology/other reports must include:

A. Arkansas Medicaid limits claims payment for outpatient diagnostic laboratory services and radiology/other services per beneficiary twenty-one (21) years of age or older.

B. The benefit limits apply to claims payments made to the following providers, individually or in any combination: outpatient hospitals, independent laboratories, physicians, osteopaths, podiatrists, Certified Nurse-Midwives (CNMs), Nurse Practitioners (NP), and Ambulatory Surgical Centers (ASCs).

C. Requests for extensions of both benefits are considered for beneficiaries who require supportive treatment for maintaining life.

D. Extension of these benefits are automatic for patients whose primary diagnosis for the service furnished is in the following list:

E. *Obstetric (OB) ultrasounds and fetal non stress tests have benefit limits that are not exempt from Extension of Benefits request requirements. (See Section 215.041 for additional coverage information.)

F. Magnetic Resonance Imaging (MRI) is exempt from the five-hundred-dollar radiology/other services benefit limit. Medical necessity for each MRI must be documented in the beneficiary's medical record. (Refer to Section 270.000 for billing information.)

G. Cardiac catheterization procedures are exempt from the five-hundred-dollar outpatient diagnostic laboratory services benefit limit and the five-hundred-dollar radiology/other benefit limit. Medical necessity for each procedure must be documented in the beneficiaries' medical record.

H. There are no benefit limits on outpatient diagnostic laboratory services or radiology/other services for beneficiaries under twenty-one (21) in the Child Health Services/Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program, except for the limitations on fetal echography (ultrasound) and fetal non-stress tests.

* OB ultrasounds and fetal non stress tests are not exempt from Extension of Benefits. See Section 215.041 for additional coverage information.

A. The Medicaid Program's diagnostic laboratory services and radiology/other services benefit limits apply to the outpatient setting.

B. Requests to extend benefits for outpatient hospital visits and diagnostic laboratory or X-ray services, including those for fetal ultrasounds and fetal non-stress tests, must be submitted to DHS or its designated vendor.

View or print contact information to obtain instructions for submitting the benefit extension request.

Benefit extension requests are considered only after a claim has been filed and denied because the benefit is exhausted.

C. Submit a copy of the Medical Assistance Remittance and Status Report that reflects the claim's denial for exhausted benefits with the request. Do not send a claim.

D. A benefit extension request must be received within ninety (90) calendar days of the date of the benefits-exhausted denial.

E. Additional information will be requested, as needed, to process a benefit extension request. Reconsiderations of additionally requested information are not available. Failure to provide requested information within the specified time will result in a technical denial.

F. Correspondence regarding benefit extension requests and requests for reconsideration of denied benefit extension requests does not constitute documentation or proof of timely claim filing.

A. The Medicaid Program's diagnostic laboratory services and radiology/other services benefit limits apply to the outpatient setting.

B. Benefit extension requests will be considered only when the provider has correctly completed all applicable fields of the "Request for Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services," form (Form DMS-671). View or print Form DMS-671.

C. The date of the request and the signature of the provider's authorized representative are required on the form. Stamped or electronic signatures are accepted.

D. Dates of service must be listed in chronological order on Form DMS-671. When requesting benefit extensions for more than four (4) procedures, use a separate form for each set of procedures.

E. Enter a valid ICD diagnosis code and a brief narrative description of the diagnosis.

F. Enter a valid revenue code or procedure code (and modifiers when applicable) and a brief narrative description of the procedure.

G. Enter the number of units of service requested under the extension.

A. The procedure codes in the link below are covered for computed tomographic (CT) colonography for beneficiaries of all ages.

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

B. CT colonography policy and billing:

C. Documentation requirements and utilization guidelines:

A. Requests for extended therapy services for beneficiaries under twenty-one (21) years of age must be submitted to DHS or its designated vendor.

View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting extended therapy services for beneficiaries undertwenty-one (21) years of age.

The request must meet the medical necessity requirement, and adequate documentation must be provided to support this request.

B. Form DMS-671, "Request for Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services," must be utilized when requesting extended therapy services. View or print Form DMS-671. Consideration of requests requires correct completion of all fields on this form. The instructions for completion of this form are located on the back of the form. The provider must sign, include credentials, and date the request form. An electronic signature is accepted, provided it complies with Arkansas Code Annotated § 25-31-103. All applicable records that support the medical necessity of the request must be attached.

C. DHS or its designated vendor will approve, deny, or ask for additional information within thirty (30) calendar days of receiving the request. Reviewers will simultaneously advise the provider and the beneficiary when a request is denied. Approved requests will be returned to the provider with an authorization.

A. Authorized procedure codes are payable for the tissue typing for both the donor and the receiver.

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

B. The tissue typing is subject to the following benefit limits:

C. Medicaid will authorize up to ten (10) tissue-typing diagnostic laboratory procedures to determine a match for an unrelated bone marrow donor.

D. A separate claim must be filed for the tissue typing.

E. Claims for the donor must be forwarded to the Transplant Coordinator.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Medicaid established a maximum amount (benefit limit) of five hundred dollar ($500) per SFY for diagnostic laboratory services and five hundred dollars ($500) per SFY for radiology/other services for beneficiaries twenty-one (21) years of age and older.

Exceptions are listed below:

C. *Obstetric (OB) ultrasounds and fetal non-stress tests have benefit limits and are not exempt from Extension of Benefits request requirements. (See Section 214.630 for additional coverage information.)

D. Extension of benefit requests are considered for clients who require supportive treatment, such as dialysis, radiation therapy, or chemotherapy for maintaining life.

E. Benefits may be extended for other conditions documented as medically necessary.

A. Nurse practitioners who perform diagnostic laboratory services or radiology/other services within their scope of practice may request extension of benefits for those services if the patient has exhausted the benefit limit.

B. To request an extension of benefits for diagnostic laboratory services or radiology/other services, use the following procedures.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Requests for extension of benefits for diagnostic laboratory services or radiology/other services must be submitted to DHS or its designated vendor.

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

C. A request for extension of benefits must be received within ninety (90) calendar days of the date of benefit limit denial.

D. Additional information will be requested, as needed, to process a benefit extension request. Reconsiderations of additionally requested information are not available. Failure to provide requested information within the specified time will result in a technical denial.

E. Correspondence regarding benefit extension requests and requests for reconsideration of denied benefit extension requests do not constitute documentation or proof of timely claim filing.

A. The Medicaid Program's diagnostic laboratory services limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Requests for extension of benefits for clinical services (such as physician's visits or Nurse Practitioner visits), outpatient services (meaning, hospital outpatient visits), diagnostic laboratory services (meaning, laboratory tests) and radiology/other services 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.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. To request extension of benefits for any services with benefit limits, all applicable records that support the medical necessity of extended benefits are required.

C. Documentation requirements are as follows.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit, each applies to the outpatient setting.

B. Medicaid established a maximum amount (benefit limit) of five hundred dollars ($500) per SFY for diagnostic laboratory services and five hundred dollars ($500) per SFY for radiology/other services, for clients twenty-one (21) years of age.

C. Extension-of-benefit requests are considered for medically necessary services.

D. Magnetic resonance imaging (MRI) services are exempt from the five-hundred-dollar ($500) outpatient radiology/other benefit limit. Medical necessity for each MRI must be documented in the client's medical record.

E. Cardiac catheterization procedures are exempt from the five-hundred-dollar ($500) SFY benefit limit (each) for outpatient laboratory services and for radiology/other services. Medical necessity for each procedure must be documented in the client's medical record.

A. The Medicaid Program's diagnostic laboratory services and radiology/other services benefit limits apply to the outpatient setting.

B. Requests for extension of benefits for diagnostic laboratory, radiology/other, physician office, and outpatient services must be submitted to Department of Human Services (DHS) or its designated vendor.

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

C. A request for extension of benefits must be received within ninety (90) calendar days of the date of the benefits-exhausted denial.

D. Additional information will be requested as needed to process a benefit extension request. Reconsiderations of additionally requested information are not available. Failure to provide requested information within the specified time will result in a technical denial.

E. Correspondence regarding benefit extension requests and requests for reconsideration of denied benefit extension requests, does not constitute documentation or proof of timely claim filing.

A. The Medicaid Program's diagnostic laboratory services, and radiology/other services benefit limits apply to the outpatient setting.

B. Requests for extension of benefits for clinical services (physician's visits), outpatient services (hospital outpatient visits), diagnostic laboratory services (laboratory tests), and radiology/other services 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.

A. The Medicaid Program's diagnostic laboratory services and radiology/other services benefit limits apply to the outpatient setting.

B. To request extension of benefits for any benefit limited service, all applicable records that support the medical necessity of extended benefits are required.

C. Documentation requirements are as follows.

A. Requests for extended therapy services for clients under twenty-one (21) years of age must be submitted to DHS or its designated vendor.

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

The request must meet the medical necessity requirement, and adequate documentation must be provided to support the request.

B. Form DMS-671 ("Request for Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services") must be utilized when a person is requesting extended therapy services. View or print Form DMS-671. Consideration of requests requires correct completion of all fields on this form. The instructions for completion of this form are located on the back of the form. The provider must sign, include credentials, and date the request form. An electronic signature is accepted provided it complies with Arkansas Code Annotated § 25-31-103. All applicable documentation that supports the medical necessity of the request should be attached.

C. DHS or its designated vendor will approve, deny, or ask for additional information within thirty (30) calendar days of receiving the request. Reviewers will simultaneously advise the provider and the client when a request is denied. Approved requests will be returned to the provider with information specific to the approval.

A. Authorized procedure codes are payable for tissue typing, both for the donor and the receiver.

B. The tissue typing is subject to the following benefit limit:

C. Medicaid will authorize up to ten (10) tissue typing procedures to determine a match for an unrelated donor for a bone marrow transplant.

D. A separate claim must be filed for the tissue typing.

E. Claims for the donor must be forwarded to the Transplant Coordinator.

A. Diagnostic laboratory services and radiology/other services provided by a podiatrist will be included in the benefit limits for outpatient diagnostic laboratory services and outpatient radiology/other services for individuals twenty-one (21) years of age and over.

B. There are no benefits limit for individuals under twenty-one (21) years of age, except for the limitations on fetal echography (ultrasound) and fetal non-stress tests.

C. Benefit extensions may be granted in cases of documented medical necessity.

D. Section 242.130 contains procedure codes payable for diagnostic laboratory and radiology/other services.

A. Extension of Benefits for Medical Visits;

B. Extension of Benefits for Diagnostic Laboratory and Radiology/Other Services;

C. The Arkansas Medicaid Program exempts the following diagnoses from the extension of benefit requirements when the diagnosis is entered as the primary diagnosis:

A. Payments for portable X-ray services claims are applied to the radiology/other services benefit limit of five hundred dollars ($500) per State Fiscal Year (SFY: July 1 through June 30).

B. Diagnostic laboratory services and radiology/other services defined as Essential Health Benefits by the U.S. Preventive Services Task Force (USPSTF) are exempt from counting toward either of the two new annual caps.

View or print the essential health benefit procedure codes.

C. Beneficiaries under twenty-one (21) years of age in the Child Health Services/Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program, do not have benefit limits for portable x-ray services.

A. The Medicaid Program's diagnostic laboratory services benefit limit, and radiology/other services benefit limit each apply to the outpatient setting.

B. Requests for extension of benefits for Portable X-ray services must be submitted to DHS or its designated vendor.

View or print DHS or its designated vendor contact information for extension ofbenefits for x-ray services.

C. Benefit extension requests must be received within ninety (90) calendar days of the date of the benefits-exhausted denial.

D. Additional information will be requested as needed to process a benefit extension request. Reconsiderations of additionally requested information are not available. Failure to provide requested information within the specified time will result in a technical denial.

E. Correspondence regarding benefit extension requests and requests for reconsideration of denied benefit extension requests, does not constitute documentation or proof of timely claim filing.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Requests for extension of benefits for clinical services (physician's visits), outpatient services (hospital outpatient visits), diagnostic laboratory services (diagnostic laboratory tests) and radiology/other services must be submitted to DHS or its designated vendor.

View or print DHS or its designated vendor contact information for extension ofbenefits for how to obtain information regarding submission processes.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. To request extension of benefits for any services with benefit limits, all applicable records that support the medical necessity of extended benefits are required.

C. Documentation requirements are as follows.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Requests to extend benefits for outpatient rehabilitative hospital visits. diagnostic laboratory services, and radiology/other services must be mailed to DHS or its designated vendor.

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

Benefit extension requests are considered only after a claim has been filed and denied because the benefit is exhausted.

C. A copy of the Medical Assistance Remittance and Status Report reflecting the claim's denial for exhausted benefits must accompany the request for review. Do not send a claim.

D. Additional information needed to process a benefit extension may be requested from the provider. Failures to provide requested additional information within the specified timeline will result in technical denials, reconsiderations of which are not available.

E. A benefit extension request must be received within ninety (90) calendar days of the date of the benefits-exhausted denial.

F. Correspondence regarding benefit extension requests and requests for reconsideration of denied benefit extension requests does not constitute documentation or proof of timely claim filing.

A. The Medicaid Program's diagnostic laboratory services benefit limit, and radiology/other services benefit limit each apply to the outpatient setting.

B. Consideration of requests for benefit extensions requires correct completion of all fields of Form DMS-671, "Request for Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services." View or print Form DMS-671.

C. The request date and the signature of the provider's authorized representative are required on the form. Both stamped and electronic signatures are accepted.

D. Dates of service must be listed in chronological order on Form DMS-671. When requesting benefit extension for more than four (4) encounters, use a separate form for each set of encounters.

E. Enter a valid ICD diagnosis code and brief narrative description of the diagnosis.

F. Enter a valid revenue code or procedure code (and modifiers, when applicable) and a brief narrative description of the procedure.

G. Enter the number of units of service requested under the extension.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Records supporting the medical necessity of extended benefits must be submitted with benefit extension requests.

C. Clinical records must:

D. Diagnostic laboratory and radiology/other reports must include:

A. Requests for extended therapy services for beneficiaries under twenty-one (21) years of age must be submitted to DHS or its designated vendor.

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

The request must meet the medical necessity requirement, and adequate documentation must be provided to support this request.

B. Form DMS-671 "Request for Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services", must be utilized for requests for extended therapy services. View or print Form DMS-671. Consideration of requests requires correct completion of all fields on this form. The instructions for completion of this form are located on the back of the form. The provider must sign, include credentials, and date the request form. An electronic signature is accepted, provided it complies with Arkansas Code Annotated § 25-31-103. All applicable documentation that supports the medical necessity of the request must be attached.

C. DHS or its designated vendor will approve, deny, or ask for additional information within thirty (30) calendar days of receiving the request. Reviewers will simultaneously advise the provider and the beneficiary when a request is denied. Approved requests will be returned to the provider with an authorization number.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Benefit extension requests will be considered only when the provider has correctly completed all applicable fields of the "Request for Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services" form. (Form DMS-671). View or print Form DMS-671.

C. The date of the request and the signature of the provider's authorized representative are required on the form. Stamped and electronic signatures are accepted.

D. Dates of service must be listed in chronological order on Form DMS-671. When requesting benefit extension for more than four (4) encounters, use a separate form for each set of encounters.

E. Enter a valid ICD diagnosis code and a brief narrative description of the diagnosis.

F. Enter the revenue code, modifier(s) when applicable and the applicable nomenclature.

G. Enter the number of units (encounters) requested under the extension.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Records supporting the medical necessity of extended benefits must be submitted with benefit extension requests and requests for reconsideration of denied benefit extension requests.

C. Clinical records must:

D. Diagnostic laboratory and radiology/other reports must include:

A. Requests for extended therapy services for beneficiaries under twenty-one (21) years of age and adults receiving services in an Adult Developmental Day Treatment (ADDT) must be sent to Arkansas Medicaid's Quality Improvement Vendor (QIO).View or print the QIO contact information.The request must meet the medical necessity requirement, and adequate documentation must be provided to support this request.

B. Form DMS-671, "Request for Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services", must be utilized for requests for extended therapy services. View or print Form DMS-671. Consideration of requests requires correct completion of all fields on this form. The instructions for completion of this form are located on the back of the form. The provider must sign, including credentials, and date the request form. An electronic signature is accepted, provided it complies with Arkansas Code Annotated § 25-31-103. All applicable documentation that supports the medical necessity of the request should be attached.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. Requests for extension of benefits for clinical services (physician's visits) outpatient services (hospital outpatient visits), diagnostic laboratory services (laboratory tests), and radiology/other services must be submitted to DHS or its designated vendor for consideration.

View or print contact information to obtain instructions for submitting the request.

A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.

B. To request extension of benefits for any services with benefit limits, all applicable records that support the medical necessity of extended benefits are required.

C. Documentation requirements are as follows.

(1) The following diagnoses are specifically exempt from the five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, and the five hundred dollars ($500) per SFY radiology/other services health benefit limits:

(2) Drug screening will be specifically exempt from the five hundred dollars ($500) per SFY diagnostic laboratory services health benefit limit when the diagnosis is for Opioid Use Disorder (OUD), and the screening is ordered by an X-DEA-waivered provider as part of a Medication Assisted Treatment (MAT) plan. The cost of these screenings will not be included in the calculation of the recipient's five hundred dollars ($500) diagnostic laboratory services health benefit limit.

(3) Magnetic Resonance Imaging (MRI) and Cardiac Catheterization procedures are specifically exempt from the five hundred dollars ($500) per SFY outpatient diagnostic laboratory services benefit limit or the five hundred dollars ($500) per SFY radiology/other services health benefit limits. The cost of these procedures will not be included in the calculation of the recipient's five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, or the recipient's five hundred dollars ($500) per SFY radiology/other services health benefit limits.

(4) Portable X-Ray Services are subject to the five hundred dollars ($500) per SFY radiology/other services benefit limit.

Extensions of the benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary. Services may be provided to an eligible recipient in their place of residence upon the written order of the recipient's physician. Portable X-ray services are limited to the following:

(5) Two (2) chiropractic X-rays are covered per SFY. Chiropractic X-Ray Services are subject to the five hundred dollars ($500) benefit limit per SFY for radiology/other services. Extensions of the radiology/other services benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary.

(1) The following diagnoses are specifically exempt from the five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit, and the five hundred dollars ($500) per SFY radiology/other services health benefit limits:

(2) Drug screening will be specifically exempt from the five hundred dollars ($500) per SFY diagnostic laboratory services health benefit limit when the diagnosis is for Opioid Use Disorder (OUD), and the screening is ordered by an X-DEA-waivered provider as part of a Medication Assisted Treatment (MAT) plan. The cost of these screenings will not be included in the calculation of the recipient's five hundred dollars ($500) diagnostic laboratory or radiology/other services health benefit limits.

(3) Magnetic Resonance Imaging (MRI) and Cardiac Catheterization procedures are specifically exempt from the five hundred dollars ($500) per SFY outpatient diagnostic laboratory services benefit limit or five hundred dollars ($500) per SFY radiology/other services health benefit limit. The cost of these procedures will not be included in the calculation of the recipient's five hundred dollars ($500) per SFY diagnostic laboratory services benefit limit or the recipient's five hundred dollars ($500) per SFY radiology/other services health benefit limit.

(4) Portable X-Ray Services are subject to the five hundred dollars ($500) per SFY X-ray services benefit limit. Extensions of the benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary. Services may be provided to an eligible recipient in their residence upon the written order of the recipient's physician. Portable X-ray services are limited to the following:

(5) Two (2) chiropractic X-rays are covered per SFY. Chiropractic X-Ray Services are subject to the five hundred dollars ($500) benefit limit per SFY for radiology/other services. Extensions of the radiology/other services benefit limit for recipients twenty-one (21) years of age or older will be provided through prior authorization, if medically necessary.

a. Nursing Facility Services - Not Provided