016.06.14 Ark. Code R. 001
The Child Health Services (EPSDT) periodic and interperiodic dental screening exams consist of an inspection of the oral cavity by a licensed dentist. The purpose of the dental screening exams is to check for obvious dental abnormalities and to assure access to needed dental care. Regular screening exams should be perfonmed in accordance with the recommendations of the Child Health Services (EPSDT) periodicity schedule.
The Child Health Services (EPSDT) periodic dental screening exam is limited to two screening exams every six (6) months plus one (1) day for individuals under age 21. These benefits may be extended if documentation is provided that verifies medical necessity. See Section 262.100 to view the procedure code for periodic dental screening exams.
Individuals under age 21 enrolled in the EPSDT Program may receive an interperiodic dental screening exam twice per SPY. Extension of benefits is available in cases of medical necessity. View or print form ADA-J4S0.See Section 262.100 for the interperiodic dental screening exam procedure code.
NOTE: ARKids First-B beneficiaries may also receive an interperiodic dental screening exam twice per SFY. There is no extension of benefits for ARKids First-B beneficiaries.
Extension of benefits requests, in addition to a narrative and any supporting documentation, should be submitted to the Division of Medical Services Dental Care Unit - ATTN Dental Extension of Benefits. View or print the Division of Medical Services Dental Care Unit contact information.
Infant oral health care examinations must be based on the recommendations of the American Academy of Pediatric Dentistry. Essential elements of an infant oral health care visit are a thorough medical and dental history, oral examination, parental counseling, preventive health education and determination of appropriate periodic re-evaluation. See Section 201.500 for infomiation regarding the dentist's role in the EPSDT Program.
When requesting prior authorization for orthodontic services, the provider must complete and submit the Request for Orthodontic Treatment form (Form DMS-32-0), the ADA[GREATER THAN]i436 claim form for the orthodontic records and a written treatrnent p[an along with the orthodontic records. View or print form DMS-32-0. View or print form ADA-J43Q."
Mail the requested information to'thet)ivislon of Medical Services Dental Care Unit. For electronic submissions options, contact the Division of Medical Services Dental Care Unit. View or print the Division of Medical iServices Dental Care Unit contact information.
Dental providers must complete the ADA claim form when;
Claims submitted on paper will be paid only once a month. The only claims exempt from this process are those that require attachments or manual pricing.
The same ADA claim form on which the treatment plan was submitted to obtain prior authorization must be used to submit the claim for payment. If this Is done, the header information and the "Request for Payment for Services Provided" portions of the form are to be completed.
The provider should carefully read and adhere to the following instructions so that claims can be processed efficiently. Accuracy, completeness and clarity are important. Claims cannot be processed if applicable information is not supplied or is illegible. Claims should be typed whenever possible. Handwritten claims must be completed neatly and accurately.
If this fomn is being used to request Prior Authorization, it should be forwarded to the Division of Medical Services Medical Assistance Attention Dental Services. View or print the Division of Medical Services Dental Unit contact information.
Completed claim forms should be forwarded to the HP Enterprise Services Claims Department. View or print the HP Enterprise Services Claims Department contact information.
To bill for dental or orthodontic services, the ADA claim form must be completed. The following nunibered items correspond to the numbered fields on the claim form. View or print form ADA-5430.
NOTE: A provider rendering services without verifying eligibility for each date of service does so at the risk of not being reimbursed for the services.
COMPLETION OF FORM
Field Number and Name | Instructions for Completion |
HEADER INFORMATION | |
1. Type of Transaction | Check one of the following: Statement of Actual Services EPSDT/TitleXIX Request for Predetennination/Preauthorization |
2. Predetermination/ Preauthorization Number | If the procedure(s) being billed requires prior authorization and authorization is granted by the Medicaid Dental Program, enter the 10-digit PA control number assigned by the Medicaid Program. |
INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION | |
3. Company/Plan Name, Address, City, State, Zip Code | Enter the canler's name and address. |
OTHER COVERAGE | |
4. Dental'? Medical? | jCheck the applicable box and complete items 5-11. if none, leave blank. (If both, complete 5-11 for dental pniy) |
5. Name of Policyholder/Subscriber in #4. | Enter Policyholder/Subscriber's name. Format: Last name, first name. |
6. Date of Birth | Enter Policyholder/Subscriber's date of birth. Format: MM/DD/CCYY. |
7. Gender | Check M for male or F for female. |
8. Policyholder/Subscriber ID | Enter the Social Security number or ID number of the Policyholder/Subscriber. |
9. Plan/Group Number | Not required. |
10. Patient's Relationship to Person Named in #5 | Check one of the following: Self Spouse Dependent Other |
11. Other Insurance Company/Dental Benefit Plan Name, Address, City, State, Zip Code | Enter the name and address of the other company providing dental or medical coverage. |
POLICYHOLDER/SUBSCRIBER INFORMA TION {For Insurance Company Named in #3) | |
12. Policyholder/Subscriber Name {Last, First, Middle Initial) 3uffix)/"Ad"dress;"City, State, Zip Code | Enter the name and address of the policyholder/subscriberof the insurance identified in item 3. |
13. Date of Birth | Enter the policyholder/subscriber's date of birth. Format: MM/DD/CCYY. |
14. Gender | Check M for male or F for female. |
15. Policyholder/Subscriber ID | Enter the Social Security number or ID number of the Policyholder/Subscriber.' |
16. Plan/Group Number | Enter the plan or group number for the insurance identified in item 3. |
17. Employer Name | Not required. |
PATIENT INFORMATION | |
18. Relationship to Policyholder/Subscriber in #12 Above. | Check one of the follovifing: Self Spouse Dependent Child Other |
19. Reserved for Future Use | |
20. Name (Last," Fiiit," Middle ilnitial'Suffix),'Address, City, State, Zip Code | Enter last name, first name, middle initial, suffix, address, city, state and Zip code. |
21. Date of Birth | Enter the patient's date of birth. Format: MM/DD/CCYY. |
22. Gender | Check "M" for male or "F" forfemale. |
23. Patient ID/Account # (Assigned by Dentist) | Enter the patient IID/Accdurit # assigned byth'e dentist.' |
RECORD OF SERVICES PROVIDED | |
24. Procedure Date | Enter the date on which the procedure was performed. Fomfiat: MM/DD/CCYY. |
25. Area of Oral Cavity | Not required. |
26. Tooth System | Not required. |
27. Tooth Number(s) or Letter(s) | Required if applicable. List only one tooth number per line. |
28. Tooth Surface | Required if applicable. Enter one of the following: M - Mesial D - Distal L - Lingual 1 - Incisal B - Buccal 0 - Occlusal L - Labial F - Facial |
29. Procedure Code | Required for Medicaid. These codes are listed in Section 262.100 for beneficiaries under age 21 or Section 262.200 for medically eligible beneficiaries age 21 and older. |
29aTDiag: Pointer | Diagnosis Code"Pointer. Enter A-D as applicable from item 34a.' |
29b"'Qtx? | Quantity. Indicates the riurhber of unitsof the procedure code(s) listed in field 29i |
30. Description | Required for Medicaid. |
31. Fee | List the usual and customary fee. |
31a. Other Fee(s) | Enter the total of payments previously received on thjs claim from any private insurance. Do not include amounts previously paid by Medicaid. Do not inclucle in this total the automatlcally deducted Medicaid or ARKids First-B copayments.' |
32. Total Fee | Required for Medicaid. Enter the total fee charged. |
33. Missing Teeth Inforrnation (Place an 'X' on each missing tooth), | Draw an X through the number of each missing toothl |
34. Diagnosis Code List Qualifier | pntef B fo7lCD-9-CM oTAB foTlCD-10-CM.' |
34aT biagnosirCo3e(s)'(Primary IBiagnosis in "A") | [Eriterup to'four diagnosis codes in A-D. Enter the Iprimary diagnosis in A.' |
35. Remarks | Not required. |
AUTHORIZATIONS | |
36. Agreement of responsibility | Patient or guardian must sign and date here. |
37. Authorization of direct payment | Subscriber must sign and date here. |
ANCILLARY CLAIM/TREATMENT INFORMATION | |
38. Place of Treatment (e.g. 11=Office: 22=0/P Hospital) (Use "Place of Service Codes for Professional Claims") | Enter the two-digit Place of Service Code for Professional Claims, a HIPAA standard malritllned by the Centers for Medicare and Medicaid Services.' Frequently used codes are: |
11-Office 12-Home 21-lnpatlent Hospital 22-Outpatlent Hospital 31-Skllled Nursing Facility 32-Nursing Facility | |
The full list is available online at httD://www.cms.qov/PhvsiciariFeeSched/DownJoad | |
s/Websife POS database.pdf. | |
39. Enclosures (Yor N) | If there are enclosures such as radiographs, oral images or models, enter Y for Yes. _ If there are no lenclosur;es, enter N for No. |
40. Is Treatment for Orthodontics? | Check No or Yes. If No, skip Items 41 and 42. If Yes? complete itemsjtl and 42] |
41. Date Appliance Placed | Enter date appliance placed. Format: MM/DD/CCYY. |
42. Months of Treatment Remaining | Enter months of orthodontic treatment remaining. |
43. Replacement of Prosthesis | Check No or Yes. If Yes, complete item 44. |
44. Date pf Prior Placement | Enter the date of prior placement of the prosthesis. Format: MM/DD/CCYY. |
45. Treatment Resulting from | Check one of the following, if applicable; Occupational illness/injury Auto accident Other accident If item 45 is applicable, complete item 46. If Item 45 is "Auto accident," also complete item 47. |
46. Date of accident | Enter date of accident. Format: MM/DD/CCYY. |
47. Auto Accident State | Enter two-letter abbreviation for state in which auto accident occurred. |
BILLING DENTIST OR DENTAL g jSubmiWng claim on behalf of tfie | V7/7Y (Leave biahk'if 'dentist "oTdental entity is hoi patient or insured/subscriber.) |
48. Name, Address, City, State, Zip Code | Enter the name and address of the billing dentist or dental entity. |
49. NPI | Not required. |
50. License Number | Optional. |
51. SSNorTIN | Optional. |
52. Phone Number | Enter the 10-digit telephone number of the billing dentist or dental entity, beginning with area code. |
52a. Additional Provider ID | Enter the Dentist or Oral Surgeon's 9-digit Arkansas Medicaid billing provider number. The provider number should end with "08" for an individual Dentist number or "31" for a Dental group. The pnDvider number should end in "79" for an Individual Oral Surgeon number or "80" for an Oral Surgeon group. |
TREATING DENTiSTAND TREATMENT LOCATION INFORMATION | |
53. Certifrcation | The provider or designated authorized Individual must sign and date the claim form certifying that the services w/ere personally rendered by the provider or under the provider's direction. "Provider's signature" is defined as the provider's actual signature, a rubber stamp of the provider's signature, an automated signature, a typevk/rltten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. |
54. NPI | Not required. |
55. License Number | Optional. |
56. Address, City, State, Zip Code | Enter the complete address of the treating dentist. |
56a. Provider Specialty Code | Indicates the type of dental professional who delivered ihe treatment. The general code listed as "Dentisf _ may be used instead of any of the other codes. For a complete list of codes, see the Provider Specialty table in the instructions accompanying the ADA-J430 claim form. View or print form ADA-J430.' |
57. Phone Number | Enter the 10-digit telephone number of the treating dentist, beginning with area code. |
58. Additional Provider ID | If the billing provider number In Field 52a is a group or clinic ending in "31" for Dentists or "80" for Oral Surgeons, the individual provider number must be entered for the provider rendering the service. The provider number should end with "08" for an individual Dentist number or "79" for an individual Oral Surgeon number. |
Section V
FORMS
500.000
Claim Forms
Red-ink Claim Forms
The following is a list of the red-ink claim forms required by Arkansas Medicaid. The forms below cannot be printed from this manual for use. Information about where to get the forms and links to samples of the forms is available below. To view a sample form, click the form name.
Claim Type | Where To Get Them |
Professional - CI\/IS-1500 | Business Form Supplier |
Institutional - CMS-1450* | Business Form Supplier |
Visual Care-DMS-26-V | 1-800-457-4454 |
Inpatient Crossover - HP-MC-001 | 1-800-457-4454 |
Lena Term Care Crossover - HP-MC-002 | 1-800-457-4454 |
Outoatient Crossover - HP-MC-003 | 1-800-457-4454 |
Professional Crossover - HP-MC-004 | 1-800-457-4454 |
* For dates of service after 11/30/07 - ALL HOSPICE PROVIDERS USE ONLY FORM CMS-1450 (formerly UB-04) for billing.
Claim Forms
The following is a list of the non-red-ink claim forms required by Arkansas Medicaid. Information about where to get a supply of the forms and links to samples of the forms is available below. To view a sample form, click the form name.
Claim Type | Where To Get Them |
Alternatives Attendant Care Provider Claim Form - | Client Employer |
AAS-9559 | |
bentar-ADA-J430 | Business Form Supplier |
Arkansas Medicaid Forms
The forms below can be printed from this manual for use.
In order by form name:
Form Name | Form Link |
Acknowledgement of Hysterectomy Information | DIVIS-2606 |
Address Change Form | DMS-673 |
Adjustment Request Form - Medicaid XIX | HP-AR-004 |
Adverse Effects Form | DMS-2704 |
AFMC Prescription & Prior Authorization Request for iVledical Equipment Excluding Wheelchairs & Wheelchair Components | DMS-679A |
Amplification/Assistive Technology Recommendation Form | DMS-686 |
Application for WebRA Hardship Waiver | DMS-7736 |
Approval/Denial Codes for Inpatient Psychiatric Services | DMS-2687 |
Arkansas Early Intervention Infant & Toddler Program Intake/Referral/Application for Services | DDS/FS#0001.a |
ARKids First Mental Health Services Provider Qualification Form | DMS-612 |
Authorization for Automatic Deposit | autodeposit |
Authorization for Payment for Services Provided | MAP-8 |
Certification of Need - Medicaid Inpatient Psychiatric Services for Under Age 21 | DMS-2633 |
Certification of Schools to Provide Comprehensive EPSDT Services | CSPC-EPSDT |
Certification Statement for Abortion | DMS-2698 |
Change of Ownership Information | DMS-0688 |
Child Health Management Services Enrollment Orders | DMS-201 |
Child Health Management Services Discharge Notification Form | DMS-202 |
CHMS Benefit Extension for Diagnosis/Evaluation Procedures | DMS-699A |
CHMS Request for Prior Authorization | DMS-102 |
Claim Correction Request | DMS-2647 |
Consent for Release of Information | DMS-619 |
Contact Lens Prior Authorization Request Form | DMS-0101 |
Contract to Participate in the Arkansas Medical Assistance Program | DMS-653 |
DDTCS Transportation Log | DMS-638 |
DDTCS Transportation Survey | DMS-632 |
Dental Treatment Additional Information | DMS-32-A |
Disclosure of Significant Business Transactions | DMS-689 |
Disproportionate Share Questionnaire | DMS-628 |
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Prescription/Referral For Medically Necessary Services/Items Not Specifically Included in the Medicaid State Plan | DMS-693 |
Early Childhood Special Education Referral Form | ECSE-R |
EPSDT Provider Agreement | DMS-831 |
Explanation of Check Refund | HP-CR-002 |
Gait Analysis Full Body | DMS-647 |
Home Health Certification and Plan of Care | CMS-485 |
Hospital/Physician/Certified Nurse Midwife Referral for Newborn Infant Medicaid Coverage | DCO-645 |
Inpatient Psychiatric Medicaid Agency Review Team Transmittal Sheet | DMS-2685 |
Individual Renewal Form for School-Based Audiologists | DMS-7782 |
Lower-Limb Prosthetic Evaluation | DMS-650 |
Lower-Limb Prosthetic Prescription | DMS-651 |
Media Selection/E-Mail Address Change Form | HP-MS-005 |
Medicaid Claim Inquiry Form | HP-CI-003 |
Medicaid Form Request | HP-MFR-001 |
Medical Equipment Request for Prior Authorization & Prescription | DMS-679 |
Medical Transportation and Personal Assistant Verification | DMS-616 |
Mental Health Services Provider Qualification Form for LCSW, LMFT and LPC | DMS-633 |
Notice Of Noncompliance | DMS-635 |
NPI Reporting Form | DMS-683 |
Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21 Prescription/Referral | DMS-640 |
Ownership and Conviction Disclosure | DMS-675 |
Personal Care Assessment and Service Plan | DMS-618Enalish DMS-618SDanish |
Practitioner Identification Number Request Form | DMS-7708 |
Prescription & Prior Authorization Request For Nutrition Therapy & Supplies | DMS-2615 |
Primary Care Physician Managed Care Program Referral Form | DMS-2610 |
Primary Care Physician Participation Agreement | DMS-2608 |
Primary Care Physician Selection and Change Form | DMS-2609 |
Procedure Code/NDC Detail Attachment Form | DMS-664 |
Provider Application | DMS-652 |
Provider Communication Form | AAS-9502 |
Provider Data Sharing Agreement - Medicare Parts C & D | DI\/IS-652-A |
Provider Enrollment Application and Contract Package | ApDiication Packet |
Quarterly Monitoring Fomn | AAS-9506 |
Referral for Audiotogy Services - School-Based Setting | DMS-7783 |
Referral for Certification of Need Medicaid Inpatient Psychiatric Services for Under Age 21 | DMS-2634 |
Referral for Medical Assistance | DMS-630 |
Request for Appeal | DMS-840 |
Request for Extension of Benefits | DMS-699 |
Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services | DMS-671 |
Request for Extension of Benefits for Medical Supplies for Medicaid Beneficiaries Under Age 21 | DMS-602 |
Request for Molecular Pathology Laboratory Services | DMS-841 |
Request For Orthodontic Treatment | DMS-32-0 |
Request for Private Duty Nursing Services Prior Authorization and Prescription - initial Request or Recertification | DIVIS-2692 |
Request for Targeted Case Management Prior Authorization for Beneficiaries Under Age 21 | DMS-601 |
Research Request Form | HP-0288 |
Service Log - Personal Care Delivery and Aides Notes | DMS-873 |
Steriiization Consent Form | DMS-615Enqli5h DMS-615 Spanish |
Sterilization Consent Form - Information for Men | PUB-020 |
Sterilization Consent Form - Information for Women | PUB-019 |
Upper-Limb Prosthetic Evaluation | DMS-648 |
Upper-Limb Prosthetic Prescription | DMS-649 |
Vendor Performance Report | VendorDerformreoort |
Verification of Medical Services | DMS-2618 |
In order by form number:
AAS-9502 | DMS-2618 | DMS-618 | DMS-664 | ECSE-R |
AAS-9506 | DMS-2633 | Ennlish | DMS-671 | HP-0288 |
AAS-9559 | DMS-2634 | DMS-618 Spanish | DMS-675 | HP-AR-004 |
Address | DWIS-2647 | DMS-619 | DMS-673 | HP-CI-003 |
Chanqe | DMS-2685 | niuiQ COD | DMS-679 | HP-CR-002 |
AutodeDosit | DMS-2687 | DMS-630 | DMS-679A | HP-MFR-001 |
CMS-485 | DMS-26g2 | DMS-632 | DMS-683 | HP-MS-005 |
CSPC-EPSDT | DMS-2698 | nuiQ coo | DMS-686 | MAP-8 |
DCO-645 | DMS-2704 | DMS-635 | DMS-689 | Performance |
DDS/FS#0001.a | DMS-32-A | DMS-638 | DMS-693 | Report |
DMS-0101 | niui«s-'i5_n | DMS-640 | Provider | |
DMS-0688 | DMS-601 | DMS-640 DMS-(i47 | DMS-699A | Enrollment Application |
DMS-102 | DMS-602 | DMS-648 | DMS-7708 | and Contract |
DMS-201 | DMS-612 | DMS-649 | DMS-7736 | PUB-019 |
DMS-202 | DMS-615 | DM$-650 | DMS-7782 | PUB-020 |
DMS-2606 | Enqlish | DMS-7783 | ||
DMS-2608 | DMS-615 | DMS-651 | DMS-831 | |
DMS-2609 | Spanish | DMS-652 | DMS-840 | |
DMS-2610 | DMS-616 | DMS-652-A | DMS-841 | |
DMS-2615 | DMS-653 | DMS-873 |
Arkansas Medicaid Contacts and Links
Click the link to view the information.
American Hospital Association
Americans with Disabilities Act Coordinator
Arkansas Department of Education, Health and Nursing Services Specialist
Arkansas Department of Education, Special Education
Arkansas Department of Human Services. Division of Aging and Adult Services
Arkansas Department of Human Services. Appeals and Hearings Section
Arkansas Department of Human Services. Division of Behavioral Health Services
Arkansas Department of Human Services. Division of Child Care and Early Childhood Education, Child Care Licensing Unit
Arkansas Department of Human Services. Division of Children and Family Services. Contracts Management Unit
Arkansas Department of Human Services. Children's Services
Arkansas Department of Human Services, Division of County Operations, Customer Assistance Section
Arlransas Department of Human Services, Division of Medical Services
Arkansas DHS, Division of IVIedical Services Director
Arkansas DHS. Division of IWedical Services, Benefit Extension Requests, UR Section
Arkansas DHS. Division of IWedical Services, Dental Care Unit
Arkansas DHS, Division of Medical Services, HP Enterprise Services Provider Enrollment Unit
Arkansas DHS. Division of Medical Services, Financial Activities Unit
Arkansas DHS. Division of Medical Services, Hearing Aid Consultant
Arkansas DHS. Division of Medical Services. Medical Assistance Unit
Arkansas DHS. Division of Medical Services, Medical Director for Clinical Affairs
Arkansas DHS. Division of Medical Services. Pliarmacy Unit
Arkansas DHS. Division of Medical Services. Program Communications Unit
Arkansas DHS. Division of Medical Services. Program Integrity Unit (PI)
Arkansas DHS. Division of Medical Services. Provider Reimbursement Unit
Arkansas DHS. Division of Medical Services. Third-Party Liability Unit
Arkansas DHS. Division of Medical Services. UR/Home Health Extensions
Arkansas DHS, Division of Medical Services. Utilization Review Section
Arkansas DHS. Division of Medical Services. Visual Care Coordinator
Arkansas Department of Health
Arkansas Department of Health. Health Facility Services
Arkansas Department of Human Services, Accounts Receivable
Arkansas Foundation For Medical Care
Arkansas Hospital Association
ARKids First-B
ARKids First-B ID Card Example
Central Child Health Services Office fEPSDT)
ConnectCare Helpline
County Codes
CPT Ordering
Dental Contractor
HP Enterprise Services Claims Department
HP Enterprise Services EDI Support Center (formerly AEVCS Help Desk)
HP Enterprise Services Inquiry Unit
HP Enterprise Services Manual Order
HP Enterprise Services Pharmacy Help Desk
HP Enterprise Services Provider Assistance Center (PAC)
HP Enterprise Services Supplied Forms
Example of Beneficiary Notification of Denied ARKids First-B Claim
Example of Beneficiary Notification of Denied Medicaid Claim
First Connections Infant & Toddler Program. Developmental Disabilities Services
Flow Chart of Intake and Prior Authorization Process For Intervention/Treatment
Health Care Declarations
ICD-9-CM. CPT. and HCPCS Reference Book Ordering
Immunizations Registry Help Desk
Medicaid ID Card Example
Medicaid Managed Care Services (MMCS)
Medicaid Reimbursement Unit Communications Hotline
Medicaid Tooth Numbering System
National Supplier Clearinghouse
Partners Provider Certification
Primary Care Physician (PCP) Enrollment Voice Response System
Provider Qualifications. Division of Behavioral Health Services
QSource of Arkiansas
Select Optical
Standard Register
Table of Desirable Weights
U.S. Government Printing Office
ValueQptions
Vendor Performance Report
016.06.14 Ark. Code R. 001