Statutes, codes, and regulations
Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.17-013 - Prosthetics 2-16; Section V 7-16

016.06.17 Ark. Code R. 013

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Current through Register Vol. 49, No. 10, October, 2024
Rule 016.06.17-013 - Prosthetics 2-16; Section V 7-16
Section II Prosthetics
242.191 Wheelchairs and Wheelchair Seating Systems for Individuals Ages 5-1-17

Two Through Adult

Arkansas Medicaid covers wheelchairs and wheelchair seating systems for individuals ages two through adult.

For any item to be covered by Arkansas Medicaid, the beneficiary must be eligible for a defined Medicaid Aid Category. Coverage is subject to the requirement that the equipment must be medically necessary for the diagnosis or treatment of an illness or injury to improve the functioning of an affected body part, and must meet all other Medicaid statutory and regulatory requirements and established criteria.

The beneficiary's diagnosis must warrant the type of equipment being purchased. Items may not be covered in every instance.

Providers are cautioned that an approved prior authorization does not guarantee payment. Reimbursement is contingent upon eligibility of both the beneficiary and the provider at the time service is provided and submission of an accurate and complete request. The DME provider is responsible for verifying the eligibility of the beneficiary at the time service is provided.

Specialized wheelchairs and wheelchair seating systems must be ordered by a physician.

When a request is submitted for a power wheelchair, Power-Operated Vehicle (POV) or specialized manual wheelchair, the following Medicaid requirements must be met:

A. A Prescription & Prior Authorization Request for Medical Equipment form (DMS-679) must be completed and submitted. This form must not be altered by the provider. View or print form DMS-679 and instructions for completion.
B. The DMS-679 must be signed and dated by the beneficiary's PCP or the ordering physician. The signature must be original. Stamp signatures are not acceptable. Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code § 25-31-103etseq.
C. Correct Medicaid procedure codes and modifiers must be utilized. Requested items will be denied if correct procedures codes and modifiers are not used.
D. All requests for prior authorization must be legible (felt pens must not be used).
E. Medicaid requires the submission of the original request.
F. Medical documentation from the beneficiary's PCP or ordering physician which included a detailed face-to-face medical examination must be submitted to establish medical necessity.
G. An Evaluation for Wheelchair and Wheelchair Seating form (DMS-0843) must be submitted. This evaluation will be completed in three parts:
1. Part A-to be completed by the DME provider.
2. Part B-to be completed by the assistive technology practitioner or can be completed by a physical therapist or occupational therapist or seating specialist for Group 1 (one) and Group 2 (two) power wheelchairs with no power options.
3. Part C-to be completed by the beneficiary's PCP or the ordering physician.
4. An Evaluation for Wheelchair and Wheelchair Seating form (DMS-0843) must be completed for all specialized wheelchairs except for rental wheelchairs. View or print form DMS-0843 and instructions for completion.

Wheelchairs and Wheelchair Seating Systems for Individuals Ages Two Through Aduit (Section 242.191)

Procedure Code

M1

M2

Description

PA

Payment Method

E0700

NU EP

U1 U1

Safety equipment, e.g., belt, harness or vest

N****

Purchase

E0700

NU EP

U2

U2

***(Travel restraint auto safe harness, E-Z on vest, no known comparable product) Safety equipment, e.g., belt, harness or vest

N****

Purchase

E0950

NU EP

***(Tray for W/C) W/C accessory, tray, each

Y

Purchase

E0950

NU

EP

U2 U2

***(ABS tray, 4-SM 5-LG) W/C accessory, tray, each

Y

Purchase

£0950

NU

EP

U3 U3

***(W/C Tray, Custom) W/C accessory, tray, each

Y

Purchase

E0950

NU EP

U4 U4

***(Tray, customized) W/C accessory, tray, each

N

Purchase

E0950

NU

EP

U5 U5

***(Clear upper Ex support system) W/C accessory, tray, each

Y

Purchase

E0950

NU EP

U6 U6

***(Lap Tray Switch Array) Wheelchair accessory, tray, each

Y

Purchase

E0950

NU EP

U7 U7

Wheelchair accessory, tray, each

Y

Purchase

E0950

NU

EP

UE

U7 U7

***(Removable Hinged Overlay for Tray) W/C accessory, tray, each

v****

Purchase

E0950

NU EP

U8

U8

***(Lap Tray for Switch Array) Wheelchair accessory, tray, each

Y

Purchase

E0951

NU EP

Heel loop/holder, with or without ankle strap, each

N****

Purchase

E0952

NU EP

Toe loop/holder, each

N****

Purchase

E0955

NU EP

Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each

N

Purchase

E0956

NU EP

***(Trunk supports for any W/C, other than travel, with hardware) Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each

N****

Purchase

E0956

NU

EP

U1

U1

***(Lateral trunk supports, swing-away, each) Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each

N****

Purchase

E0970

NU EP

No. 2 footplates, except for elevating leg rest

N****

Purchase

E0971

NU

EP

Anti-tipping device W/C

N****

Purchase

E0973

NU EP

W/C accessory, adjustable height, detachable armrest, complete assembly, each

N****

Purchase

E0973

NU EP

U1 U1

***(Height Adj. Arms, replacement) W/C accessory, adjustable height, detachable armrest, complete assembly, each

N****

Purchase

E0974

NU

EP

Manual wheelchair accessory, anti-rollback device (/* grade aids), each

N****

Purchase

E0978

NU EP

Wheelchair accessory, positioning belt/safety belt/pelvic strap, each

N**«

Purchase

E0978

NU

EP

U1 U1

/*(Belt, safety or chest, w/pad) Wheelchair accessory, positioning belt/safety belt/ pelvic strap, each

N

Purchase

E0978

NU

EP

U2

U2

Wheelchair accessory, positioning belt/safety belt/pelvic strap, each

N*«*

Purchase

E0980

NU

EP

/*(Chest panel, 21-SM 22-LG) Safety vest, wheelchair

N**«

Purchase

E0980

NU

EP

U1 U1

*'*(Shoulder retractors) Safety vest, W/C

N****

Purchase

E0981

NU EP

W/C accessory, seat upholstery, replacement only, each

N

Purchase

E0982

NU EP

W/C accessory, back upholstery, replacement only, each

N****

Purchase

E0982

NU EP

U1 U1

/*(Standard back upholstery replacement) W/C accessory, back upholstery, replacement only, each

N*"*

Purchase

E0990

NU

EP

/*(Elevating foot, leg rest) W/C accessory, elevating legrest, complete assembly, each

N****

Purchase

E0990

NU

EP

U1

U1

/*(Elevating legrest 90 Degree, 12" -16" Width) W/C accessory, elevating legrest, complete assembly, each

N"**

Purchase

E0992

NU EP

/* (Manual wheelchair accessory, solid seat)

N****

Purchase

E0992

NU EP

U1 U1

/*Manual w/c accessory, solid seat insert (Large adjustable solid seat w/hardware)

N****

Purchase

E0992

NU EP

U2

U2

/*(Foam and Plywood Flat Side Manual wheelchair accessory, solid seat)

N****

Purchase

E1084*

NU EP

Hemi-W/C; detachable arms, desk or full-length, swing-away, detachable, elevating leg rests

N****

Purchase

E1086*

NU EP

Hemi W/C; detachable arms, desk or full-length, swing-away, detachable footrests

N"**

Purchase

E1086*

NU EP

U1

U1

Hemi W/C, detachable arms, desk or full-length, swing-away detachable footrests

Y

Purchase

E1088*

NU EP

High strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating leg rests

Y*

Purchase

E1090

NU EP

High-strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrests

N****

Purchase

E1092*

NU EP

Wide, heavy-duty W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests

Y4

Purchase

E1093*

NU EP

Wide, heavy-duty W/C; detachable arms, desk or full-length arms, swing-away, detachable footrests

Y*

Purchase

E1110*

NU EP

Semi-reclining W/C; detachable arms, desk or full-length, elevating legrests

Y4

Purchase

E1161

NU EP

Manual adult size W/C, includes tilt in space

Y*

Purchase

E1170*

NU EP

Amputee W/C; fixed full-length arms, swing-away, detachable, elevating legrests

N****

Purchase

E1172*

NU EP

Amputee W/C; detachable arms, desk or full-length, without footrests or legrests

Y4

Purchase

E1180*

NU EP

Amputee W/C; detachable arms, desk or full-length, swing-away, detachable footrests

Y*

Purchase

E1200*

NU EP

Amputee W/C; fixed full-length arms, swing-away, detachable footrests

jyj****

Purchase

E1220*

NU EP

W/C, specially sized or constructed (indicate brand name, model number, if any, and justification)

Y

Manually Priced

E1225

NU EP

***(Folding Backrest, 8 Degree Bend, Low, 15" -16") Manual W/C accessory, semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each

N"**

Purchase

E1228

NU EP

***(Folding Backrest, Tall, 19" - 20") Special back height for W/C

N****

Purchase

E2201

NU

EP

***(Seat Width 20") Manual w/c accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN] 24 inches

N****

Purchase

E2201

NU EP

U1 U1

***(Frame Width 14"-15") Manual w/c

accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN] 24 inches

N****

Purchase

E2201

NU

EP

U2

U2

***(Frame Width 19"-20") Manual w/c accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN] 24 inches

N*"*

Purchase

E2201

NU EP

U3

U3

Manual w/c accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN] 24 inches

N****

Manually Priced

E2203

NU EP

***(Seat Depth 15") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches

N****

Purchase

E2203

NU EP

U1 U1

***(Seat Depth 17° -18") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches

(\|****

Purchase

E2203

NU

EP

U2 U2

***(Frame, Long; 16", 17"3, 18", 19"3, 20" Depth) Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches

N****

Purchase

E2203

NU

EP

U3

U3

***(Seat Depth 19" - 20") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches

N"**

Purchase

E2203

NU EP

U4 U4

Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches

N

Manually Priced

E2206

NU

EP

Manual wheelchair accessory, wheel lock assembly, complete, each

N

Purchase

E2207

NU EP

Wheelchair accessory, crutch and cane holder, each

jg****

Purchase

E2208

NU EP

Wheelchair accessory, cylinder tank carrier, each

N

Purchase

E2209

NU EP

Wheelchair accessory, arm trough, each

N

Purchase

E2210

NU

EP

Wheelchair accessory, bearings, any type, replacement only, each

N

Purchase

E2211

NU EP

Manual wheelchair accessory, pneumatic propulsion tire, any size, each

N

Purchase

E2212

NU

EP

Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each

N

Purchase

E2311

NU EP

Power w/c accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware

Y

Purchase

E2322

NU EP

Power w/c accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware

Y

Purchase

E2323

NU EP

Power w/c accessory, specialty joystick handle for hand control interface, prefabricated

Y

Purchase

E2324

NU EP

Power w/c accessory, chin cup for chin control interface

Y

Purchase

E2325

NU EP

Power w/c accessory, sip & puff interface nonproportional, including ail related electronics, mechanical stop switch, and manual swing-away mounting hardware

Y

Purchase

E2326

NU EP

Power wheelchair accessory, breath tube kit for sip and puff interface *** {replacement only)

Y

Purchase

E2327

NU EP

Power w/c accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware

Y

Purchase

E2359

NU EP

Power w/c accessory, group 34 sealed lead acid battery, each

N

Purchase

E2360

NU EP

Power w/c accessory, 22 NF non-sealed lead acid battery, each

N

Purchase

E2361

NU EP

Power w/c accessory, 22 NF sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat)

N

Purchase

E2363

NU EP

Power w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)

N

Purchase

E2363

NU EP

U1 U1

Power w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)

N

Purchase

E2365

NU EP

***(U-1 gel cell battery, each) Power wheelchair accessory, U-1 sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat)

N

Purchase

E2383

NU

EP

Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each

Y

Purchase

E2384

NU EP

Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each

Y

Purchase

E2385

NU EP

Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each

Y

Purchase

E2386

NU

EP

Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each t

Y

Purchase

E2387

NU EP

Power wheelchair accessory, foam caster tire, any size, replacement only, each

Y

Purchase

E2601

NU EP UE

General use wheelchair seat cushion,

width less than 22 in., any depth

N****

Purchase

E2602

ZUJD

General use wheelchair seat cushion, width 22 in. or greater, any depth

N

Purchase

E2611

NU EP UE

General use wheelchair back cushion, width less than 22 in., any height, including any type mounting hardware

N

Purchase

E2612

NU EP UE

General use wheelchair back cushion, width 22 in. or greater, any height, including any type mounting hardware

N

Purchase

E2619

NU EP

Replacement cover for wheelchair seat cushion or back cushion, each

N

Purchase

E2622

NU EP UE

Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth

N

Purchase

E2623

NU

EP UE

Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth

N

Purchase

E2624

NU EP UE

Skin protection and positioning wheelchair seat cushion, adjustable width less than 22 inches, any depth

N

Purchase

E2625

NU EP UE

Skin protection and positioning wheelchair seat cushion, adjustable width 22 inches or greater, any depth

N

Purchase

E2626

NU EP

Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable

Y

Purchase

K0011

NU

EP

U1 U1

*"*(Motorized, power base or conventional frame w/c DA/swing-away footrests, programmable electronics and custom options) Standard-weight frame motorized/power, W/C with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking

Y*

Purchase

K0012

NU EP

A(Motorized folding frame, DA, swing-away footrests) Lightweight portable motorized/power W/C

Y*

Purchase

K0012

NU EP

U1 U1

A(Motorized folding frame, DA, swing-away ELR) Lightweight portable motorized/power W/C

Y*

Purchase

K001412

NU EP

Other motorized/power W/C base

Y*

Purchase

K001412

NU EP

U1 U1

A (Center Drive power base) Other motorized/ power W/C base

Y*

Purchase

K001412

NU EP

U3 U3

A (Motorized, Power Base or conventional frame W/C DA/swtng-away foot rests, programmable electronics and custom options) Other motorized/power W/C base

Y*

Purchase

K00141"2

NU EP

U4 U4

A (Motorized, Power Base or conventional frame W/C DA/swtng-away elevated foot rests, programmable electronics and custom options) Other motorized/power W/C base

Y*

Purchase

K0017

NU EP

A (Receiver for height adjustable arms) Detachable, adjustable height armrest, base,each

N"**

Purchase

K0017

NU EP

U1 U1

A(Dual post and adjustable height DA) Detachable, adjustable height armrest, base,each

KJ****

Purchase

K0019

NU EP

Arm pad,each

N

Purchase

K0020

NU EP

Fixed, adjustable height armrest, pair

N"**

Purchase

K0038**

EP

U1

A (Knee strap) Leg strap, each

N

Purchase

K0038

NU EP

A(Single leg strap, each) Leg strap, each

N****

Purchase

K0038

NU EP

U2 U2

A(Foot straps, pair) Leg strap, each

hi****

Purchase

K0108

NU EP

A(W/C miscellaneous equipment; applicable pages from the manufacturer's catalog must be attached to the claim form.) Other accessories

[U****

Manually Priced

K0739

NU EP

U1 U1

***(Labor only, Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes. A maximum of twenty units per date of service is allowable, 20 units = 5 hours of labor)

Y

Purchase

S1002

EP

***(Wheelchair, custom molded seating system only) Customized item, list in addition to code for basic item

N""

Manually Priced

S1002

NU EP

U1 U1

+**(Foam-in-place seat, Pindot quick foam contour system) Customized item, list in addition to code for basic item

K|*#*t

Purchase

The following procedure codes may be billed only on paper.

Wheelchairs and Wheelchair Seating Systems for Individuals Ages Two Through Adult (Section 242.191)

No

National

Code

M1 M2

Local Code

Description

PA

Payment Method

Bill on paper

NU EP

Z1613

One-piece footboard (each)

N'*"

Purchase

Bill on paper

NU EP

Z1793

Custom foot platform

hi****

Purchase

Bill on paper

EP

Z1824**

PC Car Seat/Snug Seat

Y

Purchase

Bill on paper

NU EP

Z2137

Adjustable Rem. Abductor w/hardware (ea)

N*"*

Purchase

Bill on paper

NU EP

Z2138

Adjustable Flip Down Abductor w/hardware (ea)

K]****

Purchase

Bill on paper

NU EP

Z2139

Lateral Hip/Thigh support w/hardware (ea)

K|****

Purchase

Bill on paper

NU EP

Z2140

Adductor - no hardware

hi****

Purchase

Bill on paper

NU

EP

Z2141

Abductor - no hardware

hi****

Purchase

Bill on paper

NU EP

Z2582

Quick Release Axle

N**«

Purchase

Bill on paper

NU EP

Z2585

Growing Seat Pan

N****

Purchase

Bill on paper

NU EP

Z2586

Growing Back Upholstery

N****

Purchase

Bill on paper

NU

EP

Z2588

Deep Contour Back 20" Width

N****

Purchase

Bill on paper

NU EP

Z2589

Adjustable Contour Lateral Pelvic Support

N****

Purchase

Bill on paper

NU

EP

Z2592

Remote Joystick Module

N****

Purchase

Bill on paper

NU EP

Z2599

Transit Option

N****

Purchase

Bill on paper

NU EP

Z2604

Adjustable Back Upholstery

N****

Purchase

Bill on paper

NU EP

Z2616

Swing-away Mount (Joystick)

N****

Purchase

Required Documentation

Face-to-Face Examination

In order for Medicaid to provide reimbursement for a Power/motorized Wheelchair (PWC), Power Operated Vehicle (POV) (scooter) or specialized manual wheelchair, the following requirements must be met.

A. A face-to-face physician examination must be performed.
B. The physician must perform a medical examination for the specific purpose of assessing the beneficiary's mobility limitation and needs, The results of this exam must be recorded in the patient's medical record.
C. The prescription must be written only after the face-to-face physician examination and assessment of mobility limitations have occurred and the medical history and physical examination is completed.
D. The prescription and the medical records documenting the in-person visit and examination report must be sent to the equipment supplier within forty-five (45) days of completion of the examination.
E. The physician may refer the beneficiary to a licensed/certified professional, a Physical Therapist (PT) or Occupational Therapist (OT) to perform a wheelchair assessment.

If the beneficiary is referred to a physical/occupational therapist before the physician completes the face-to-face examination, the physician must review the physical/occupational therapist's written report and perform the final examination. The forty-five (45)-day period begins on the

E. Strollers and stroller-like chairs of any kind are not covered by Arkansas Medicaid. A stroller is a four-wheeled, often collapsible, chair-like carriage. They are helpful to caregivers and are typically used for transportation. Although stroller and stroller-like chairs may be used to transport individuals with medical conditions, such items do not serve a medical purpose. Strollers and stroller-like chairs have no positioning components for medical use, cannot be modified for growth and accommodate changes in medical or physical condition, and cannot be self-propelled by the individual.
F. Prior authorization is required even when insurance pays primary to Medicaid. Explanation of benefits (EOB) of the other insurance must be submitted with the request.
G. All wheelchair requests require a manufacturer's brand and the model name of the base.
H. In the event a wheelchair is stolen, damaged in the home, or by vehicle or fire, a police/fire report, copy of the home owners/auto insurance coverage and detailed documentation of events leading to the loss/damage are required.
I. Mobility bases for car seats are not covered by Medicaid.
J. Options, accessories, and replacement parts that are medically necessary for wheelchairs that do not have specific HCPCS codes should be coded K0108 (other accessories). The manufacturer's suggested retail price (MSRP) must be listed for each item coded K0108, and the MSRP quote to the DME provider must be included. The MSRP quote must not be altered by the DME provider. If the MSRP is altered in anyway, the request will be denied.
K. In the event a beneficiary wishes to change services from one DME provider to another DME provider, an affidavit signed and dated by the beneficiary must be submitted with the request from the new DME provider.
L. The existence of a procedure code does not necessarily indicate coverage by Arkansas Medicaid.
M. The allowed amount of a POV includes all options and accessories that are provided at the time of initial issue. This includes but is not limited to batteries, battery chargers, seating systems, etc. All options and accessories provided at the initial issue of a Power-Operated Vehicle (POV) are included and should not be billed separately.
N. If coverage criteria is not met for a specific item requested, and Arkansas Medicaid determines that another item Is more appropriate and meets medical necessity, that item will be authorized.
O. The wheelchair will significantly improve the beneficiary's ability to participate in Mobility Related Activities of Daily Living (MRADL) and the individual will use the wheelchair on a regular basis in the home.
P. The individual's home will provide adequate access between rooms, maneuvering space and surface for use of the requested wheelchair.

Non-Covered Items for Specialized Wheelchairs and Wheelchair Systems

A. Items that are deluxe in nature. Deluxe items are items of convenience that are not medically necessary. Deluxe items are often used for social purposes or convenience. Deluxe items include deluxe accessories which increase the cost of purchase or operation. Deluxe items and deluxe accessories are not covered by Arkansas Medicaid.
B. Items for use in hospitals, nursing home or other institutions.
C. Items for the beneficiary's comfort or the caregiver's convenience.
D. Two pieces of equipment that serve the same purpose.

Specialized Rehabilitative Equipment, All Ages (Section 242.192)

Procedure Code

M1

M2

Description

PA

Payment Method

E0149

NU

EP

***(4 Wheel Reverse Walker) Walker, heavy-duty, wheeled, rigid or folding, any type

N

Purchase

E0163

EP NU

U1

U1

***(Potty Chair - Small) Commode chair,

stationary, with fixed arms

Y

Purchase

E0168

EP

***(Rehab Shower/Commode Chair) Commode chair, extra wide and/or heavy-duty, stationary or mobile, with or without arms, any type, each

Y4

Purchase

E0168

EP

UB

A (Adaptive Commode Chair) Commode chair, extra wide and/or heavy-duty, stationary or mobile, with or without arms, any type, each

N

Purchase

E0168

NU

***(Adaptive Commode Chair) Commode chair, extra wide and/or heavy-duty, stationary or mobile, with or without arms, any type, each

N

Purchase

E0168

NU

U1

***(Rehab Shower/Commode Chair) Commode chair, extra wide and/or heavy-duty, stationary or mobile, with or without arms, any type, each

Yt

Purchase

E0241

NU

EP

***(Bolt-on Sm. Grab Bar) Bathroom wall rail, each

N

Purchase

E0241

NU EP

U1 U1

***(Bolt-on Lg. Grab Bar) Bathroom wall rail, each

N

Purchase

E0241

NU EP

U2

U2

***(Bolt-on Med. Grab Bar) Bathroom wall rail, each

N

Purchase

E0245

NU EP

***(Adj. Bath Chair w/Back) Tub stool or bench

N

Purchase

E0245

NU

EP

U2 U2

***(Padded Tub Transfer Bench) Tub stool or bench

N

Purchase

E0245

NU EP

U3 U3

***(30" Bath Chair) Tub stool or bench

N

Purchase

E0245

NU EP

U4 U4

***(38" Bath Chair) Tub stool or bench

N

Purchase

E0245

NU

EP

U5 U5

***(47n Bath Chair) Tub stool or bench

N

Purchase

E0245

NU EP

U6

U6

***(56" Bath Chair) Tub stool or bench

N

Purchase

E0245

NU EP

UB UB

***(Non-padded tub transfer bench) Tub stool or bench

N

Purchase

E0246

NU EP

***(Clamp-on Tub Grab Bar) Transfer tub rail attachment

N

Purchase

E1035**

EP

U2

A(Carrie Seat - Jr.) Multi-positional patient transfer system, with integrated seat, operated by care giver

Y

Purchase

E1035

NU EP

U3

U3

***(Carrie Seat - Sm. Adult) Multi-positional patient transfer system, with integrated seat, operated by care giver

Y*

Purchase

E8000

EP

&(14") Gait trainer, pediatric size, posterior support, includes all accessories and components

Y

Manually Priced

E8000

EP

U1

***(19") Gait trainer, pediatric size, posterior support, includes all accessories and components

Y

Manually Priced

E8000

EP

U2

**(Intermediate) Gait trainer, pediatric size, posterior support, includes all accessories and components

Y

Manually Priced

E8001

EP

***(14") Gait trainer, pediatric size, upright support, includes alt accessories and components

Y

Manually Priced

E8001

EP

U1

***(19") Gait trainer, pediatric size, upright support, includes all accessories and components

Y

Manually

Priced

E8001

EP

U2

***(Intermediate) Gait trainer, pediatric size, upright support, includes all accessories and components

Y

Manually Priced

E8002

EP

*%(14") Gait trainer, pediatric size, anterior support, includes all accessories and components

Y

Manually

Priced

E8002

EP

U1

***(19") Gait trainer, pediatric size, anterior support, includes all accessories and components

Y

Manually Priced

E8002

EP

U2

***(Intermediate) Gait trainer, pediatric size, anterior support, includes all accessories and components

Y

Manually Priced

The following list of codes may only be billed on paper.

Specialized Rehabilitative Equipment, All Ages (Section 242.192)

No

National Code

M1

Local Code

Description

PA

Payment Method

Bill on paper

NU EP

Z1996

Sm. 51" Supine Stander

Y*

Purchase

Bill on paper

NU

EP

Z1997

Lg. 71" Supine Stander

Y*

Purchase

Bill on paper

EP

Z1998**

27" Prone Stander

Y

Purchase

Bill on

paper

EP

22021**

Mobile Floor Sitter Med/Lg.

N

Purchase

Bill on

paper

EP

Z2038**

Therapy Ball - Sm,

N

Purchase

Bill on paper

EP

Z2039**

Therapy Ball - Med.

N

Purchase

Bill on

paper

EP

Z2040**

Therapy Ball - Lg,

N

Purchase

Bill on paper

EP

Z2043"

Seat & Back Pad for Toddler Chairs

Y

Purchase

Bill on

paper

EP

Z2044**

Tray for Toddler Chair

Y

Purchase

Bill on paper

EP

Z2045**

14" T&S High Back w/Support Activity Chair

Y

Purchase

Bill on paper

EP

Z2046**

16" T&S High Back w/Support Activity Chair

Y

Purchase

Bill on paper

NU

EP

Z2047

Orthopedic Car Seat

Y

Purchase

Bill on paper

NU EP

Z2072

Lg. Wrap Around Bath Support

N

Purchase

Bill on paper

NU

EP

Z2073

Sm. Wrap Around Back Support

N

Purchase

Bill on paper

NU

EP

Z2074

Lg. Toilet Support w/Hi Back

N

Purchase

Bill on paper

NU EP

Z2075

Sm. Toilet Support w/Hi Back

N

Purchase

Bill on paper

NU

EP

Z2077

Flexible Shower Hose

N

Purchase

Bill on paper

NU EP

Z2089

Toilet Seat Reducer Ring (Padded)

N

Purchase

Bill on

paper

NU EP

Z2093

Adult Gait Trainer

Y*

Purchase

Bill on

paper

EP

Z2094**

Tyke Strider Walker w/2 Wheels

N

Purchase

Bill on paper

EP

Z2095**

Tweener Strider Walker w/2 Wheels

N

Purchase

Bill on

paper

EP

Z2096**

Middle Strider Walker w/2 Wheels

N

Purchase

Bill on paper

NU EP

Z2097

Adult Strider Walker w/2 Wheels

N

Purchase

E. Requests for replacement where malicious damage, neglect or misuse of the equipment may have occurred may be investigated by Arkansas Medicaid. Requests may be denied if such circumstances are confirmed.
F. If a wheelchair is stolen or damaged by vehicle, fire or in the home, the beneficiary must provide the following with the request:
1. A police or fire report.
2. Copy of the homeowner's or auto insurance coverage.
3. Detailed documentation of events leading to the loss and damage.

If Arkansas Medicaid denies a repair or replacement in a case of malicious damage or misuse, payment of repairs is the responsibility of the beneficiary or caregiver.

242.195 Repairs of Specialized Wheelchairs and Wheelchair Systems 5-1-17
A. Arkansas Medicaid will cover repairs for wheelchairs and wheelchair seating.
B. Repair services must receive prior authorization from AFMC.
C. Detailed documentation from the technician that supports the equipment or services being requested must be submitted. Documentation must include the following:
1. Date and place of purchase of the current chair.
2. Brand and model name of the base.
3. Brand and model name of parts and accessories needed for repairs.
D. Correct procedure codes per the current Medicaid policy must be used.
E. Requests for repairs must be submitted on form DMS-679 {Prescription & Prior Authorization Request for Medical Equipment) and must be signed and dated by the beneficiary's PCP or ordering physician. View or print form DMS-679 and instructions for completion.
F. Repairs for previously authorized wheelchairs that the beneficiary has outgrown will not be covered if a new chair has been authorized.
G. In the event a request is submitted for repairs for a wheelchair authorized by another state agency, documentation or a delivery ticket showing that the wheelchair was authorized by another state agency must be submitted with the request.
H. Arkansas Medicaid will not cover repairs/damage due to the following:
1. Neglect.
2. Misuse.
3. Abuse.
4. Improper installation or repair by the DME provider.
5. Use of parts or changes by the DME provider or the beneficiary not authorized by Arkansas Medicaid.
I. When a request is submitted for a new wheelchair with a statement that the previous wheelchair cannot be repaired, documentation from the manufacturer of the previous chair stating the reason why the previous wheelchair cannot be repaired must be included.
J. If the previous wheelchair cannot be repaired, several color photographs taken at different angles must be included with the new request.

SECTION V -FORMS

i

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 ToGet Them

Professional - CMS-1500

Business Form Supplier

Institutional - CMS-1450*

Business Form Supplier

Visual Care - DMS-26-V

1-800-457-4454

Inoatient Crossover- HP-MC-001

1-800-457-4454

Lonq Term Care Crossover- HP-MC-002

1-800-457-4454

Outpatient 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 -AAS-9559

Client Employer

Dental - 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

DMS-2606

Address Change Form

DMS-673

Adjustment Request Form - Medicaid XIX

HP-AR-004

Adjustment Request Form - Medicaid XIX - Pharmacy Program

DMS-802

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

Evaluation for Wheelchair and Wheelchair Seating

DMS-0843

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-618 Spanish

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

In order by form number:

AAS-9502

DMS-2618

DMS-618

DMS-673

ECSE-R

AAS-9506

DMS-2633

Spanish

DMS-679

HP-0288

AAS-9559

DMS-2634

DMS-619

DMS-683

HP-AR-004

Address

DMS-2647

DMS-628

DMS-686

HP-Ct-003

Chanqe

DMS-2685

DMS-630

DMS-689

HP-CR-002

Autodeposit

DMS-2687

DMS-632

DMS-693

HP-MFR-001

CMS-485

DMS-2692

DMS-633

DMS-699

HP-MS-005

CSPC-EPSDT

DMS-2698

DMS-635

DMS-699A

MAP-8

DCO-645

DMS-2704

DMS-638

DMS-7708

Performance

DDS/FS#0001.a

DMS-32-A

DMS-640

DMS-7736

Report

DMS-0101

DMS.77.ri

DMS-647

DMS-7782

Provider

DMS-0688

riMC cru

DMS-648

DMS-7783

Enrollment

DMS-0843

UMo-DUl

DMS-649

DMS-801

Application and Contract

DMS-102

DMS-602 MS.612

DMS-650

DMS-802

Package

DMS-201

DMS-615

DMS-651

DMS-831

PUB-019

DMS-202

Enqlish

DMS-652

DMS-840

PUB-020

DMS-2606

DMS-615

DMS-652-A

DMS-841

DMS-2603

Spanish

DMS-653

DMS-844

DMS-2609

DMS-616

DMS-664

DMS-845

DMS-2610

DMS-618 Enqlish

DMS-671

DMS-846

DMS-2615

DMS-675

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 Finance Administration. Sales and Tax Use Unit

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

Hewlett Packard Enterprise EDI Support Center (formerly AEVCS Help Desk)

Hewlett Packard Enterprise Inquiry Unit

Hewlett Packard Enterprise Manual Order

Hewlett Packard Enterprise Provider Assistance Center (PAC)

Hewlett Packard Enterprise Supplied Forms

Example of Beneficiary Notification of Denied ARKids First-B Claim

Example of Beneficiary Notification of Denied Medicaid Claim

First Connections Infant & Toddler Program. Developmental Disabilities Services

First Connections Infant & Toddler Program. Developmental Disabilities Services, Appeals

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

Health Care Declarations

Immunizations Registry Help Desk

Magellan Pharmacy Call Center

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 fPCP) Enrollment Voice Response System

Provider Qualifications. Division of Behavioral Health Services

Select Optical

Standard Register

Table of Desirable Weights

U.S. Government Printing Office

ValueQptions

Vendor Performance Report

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016.06.17 Ark. Code R. 013

6/21/2017