016.06.21 Ark. Code R. 006
Approval or denial of a benefit extension request-or request for additional information-will be made within thirty (30) calendar days.
Reviewers will simultaneously advise the provider and the beneficiary when a benefit extension request is denied.
Claims for some procedures must be submitted on paper and accompanied by operative reports, consent forms or other documentation and are not accepted electronically or without the required attachments.
The procedures in this section apply to all requests for prior authorization (PA) of outpatient surgeries.
When a PA request is denied, the provider and the beneficiary have administrative and legal rights to reconsideration and appeal (explained in Sections 160.000 through 169.000 of the Arkansas Medicaid provider manual).
Requests for extension of benefits for Clinical Services (Physician's Visits), Outpatient Services (Hospital Outpatient visits), Laboratory Services (Lab Tests) and X-ray services (X-ray, Ultrasound, Electronic Monitoring - e.e.g.; e.k.g.; etc), must be submitted to DHS or its designated vendor for consideration. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting extension of benefits.
Consideration of requests for extension of benefits requires correct completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray (form DMS-671). View or print form DMS-671.
Complete instructions for accurate completion of form DMS-671 (including indication of required attachments) accompany the form.
Medicaid covers prescription drugs in accordance with policies and regulations set forth in this section and pursuant to orders (prescriptions) from authorized prescribers. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. A numeric listing of approved pharmaceutical companies and their respective labeler codes is located on the Arkansas Division of Medical Services (DMS) Pharmacy website. View or print numeric listing of approved pharmaceutical companies and the respective labeler codes. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with listed labeler codes.
PRESCRIPTION DRUG INFORMATION
View or print contact information for prescription drug prior authorization concerns and the latest information regarding prescription drug coverage.
Prescription drugs are available for reimbursement under the Arkansas Medicaid Program pursuant to an order from an authorized prescriber. Certain prescription drugs may require prior authorization.
The dental provider must request prior authorization before prescribing a prescription drug to an eligible Medicaid beneficiary.
View or print contact information for information relative to the following:
Dental providers must use the American Dental Association (ADA) form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one (1) beneficiary.
Section III of the Arkansas Medicaid provider manual contains information about available options for electronic claim submission. When billing electronically, the provider's NPI number is required.
Dental providers must complete the ADA claim form when:
For prior authorizations, the provider should send the ADA claim form to the Arkansas Division of Medical Services Dental Care Unit. View or print the Division of Medical Services Dental Care Unit contact information.
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 form 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 Claims Department. View or print the Claims Department contact information.
To bill for dental or orthodontic services, the ADA claim form must be completed. The following numbered items correspond to the numbered fields on the claim form. View or print form ADA-J430.
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/Title XIX Request for Predetermination/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 carrier's name and address. |
OTHER COVERAGE | |
4. Dental? Medical? | Check the applicable box and complete items 5-11. If none, leave blank. (If both, complete 5-11 for dental only.) |
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 INFORMATION (For Insurance Company Named in #3) | |
12. Policyholder/Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code | Enter the name and address of the policyholder/subscriber of 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 patient Medicaid ID number. |
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 following: Self Spouse Dependent Child Other |
19. Reserved for Future Use | |
20. Name (Last, First, Middle Initial, 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" for female. |
23. Patient ID/Account # (Assigned by Dentist) | Enter the patient ID/Account # assigned by the dentist. |
RECORD OF SERVICES PROVIDED | |
24. Procedure Date | Enter the date on which the procedure was performed. Format: 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 I - Incisal B - Buccal O - 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. |
29a. Diag. Pointer | Diagnosis Code Pointer. Enter A-D as applicable from item 34a. |
29b. Qty. | Quantity. Indicates the number of units of the procedure code(s) listed in field 29. |
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 this claim from any private insurance. Do not include amounts previously paid by Medicaid. Do not include in this total the automatically deducted Medicaid or ARKids First-B copayments. |
32. Total Fee | Required for Medicaid. Enter the total fee charged. |
33. Missing Teeth Information (Place an 'X' on each missing tooth) | Draw an X through the number of each missing tooth. |
34. Diagnosis Code List Qualifier | Enter B for ICD-9-CM or AB for ICD-10-CM. |
34a. Diagnosis Code(s) (Primary diagnosis in "A") | Enter up to four diagnosis codes in A-D. Enter the primary 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=O/P Hospital) (Use "Place of Service Codes for Professional Claims") | Enter the two-digit Place of Service Code for Professional Claims, a HIPAA standard maintained by the Centers for Medicare and Medicaid Services. Frequently used codes are: |
11-Office 12-Home 21-Inpatient Hospital 22-Outpatient Hospital 31-Skilled Nursing Facility 32-Nursing Facility | |
The full list is available online at http://www.cms.gov/PhysicianFeeSched/Downloads/Website_POS_database.pdf. | |
39. Enclosures (Y or N) | If there are enclosures such as radiographs, oral images or models, enter Y for Yes. If there are no enclosures, enter N for No. |
40. Is Treatment for Orthodontics? | Check No or Yes. If No, skip items 41 and 42. If Yes, complete items 41 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 of 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 ENTITY (Leave blank if dentist or dental entity is not submitting claim on behalf of the 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 | Required. |
50. License Number | Optional. |
51. SSN or TIN | 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 provider number should end in "79" for an individual Oral Surgeon number or "80" for an Oral Surgeon group. |
TREATING DENTIST AND TREATMENT LOCATION INFORMATION | |
53. Certification | The provider or designated authorized individual must sign and date the claim form certifying that the services were 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 typewritten 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 | 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 the treatment. The general code listed as "Dentist" 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. |
Medicaid covers prescription drugs in accordance with rules set forth in this section (Section 202.200) and pursuant to orders (prescriptions) from authorized prescribers. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with current rebate agreements and listed labeler codes.
Click here to obtain the latest information regarding prescription drug coverage.
Benefit extension requests are considered only after a claim has been filed and denied because the benefit is exhausted.
Approval or denial of a benefit extension request-or request for additional information-will be made within thirty (30) calendar days.
The Arkansas Department of Health and Human Services, its designees and other state and federal agencies review medical records for documentation of services provided and billed and to evaluate the medical necessity of delivered services.
Determination are made in accordance with the guidelines of the MUMP.
Sections 212.501 through 212.507 generally set forth MUMP guidelines. Sections 212.510 through 212.550 address specific issues and procedures.
Once per admission DHS or the designated vendor will reconsider a denied extension.
When a patient is transferred from another hospital (see Section 212.530 below) or when a patient's attending physician determines the patient should not be discharged by the fifth day of hospitalization, hospital utilization review or case management personnel may request an extension of inpatient days. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting MUMP certification.
When a patient is transferred from one hospital to another, the receiving facility must contact DHS or designated contractor within twenty-four (24) hours of admission to certify the inpatient stay. View or print contact information to obtain instructions for submitting the transfer request.
When eligibility is determined while the patient is still an inpatient, the hospital may request postcertification of inpatient days beyond the first four (4) (or all days if the admission was by transfer) and a concurrent certification of additional days, if needed. View or print contact information to obtain instructions for submitting the request.
If a provider did not request MUMP certification of an inpatient stay because of apparent coverage by insurance or Medicare Part A, but the other payer has denied the claim for noncovered service, lost eligibility, benefits exhausted etc., post-certification required by the MUMP may be obtained. View or print contact information to obtain instructions for submitting the request.
Benefit extension requests are considered only after a claim has been filed and denied because the benefit is exhausted.
Reconsiderations of additionally requested information are not available. Failure to provide requested information within the specified time will result in a technical denial.
Approvals or denials of a benefit extension request-or ask for additional information-shall be made within thirty (30) calendar days.
Hyperbaric Oxygen Therapy (HBOT) involves exposing the body to oxygen under pressure greater than one atmosphere. Such therapy is performed in specially constructed hyperbaric chambers holding one or more patients, although, oxygen may be administered in addition to the hyperbaric treatment itself. Patients should be assessed for contraindications such as sinus disease or claustrophobia prior to therapy. In some diagnoses, hyperbarics is only an adjunct to standard surgical therapy. These indications are taken from "The Hyperbaric Oxygen Therapy Committee Report" (2003) of The Undersea and Hyperbaric Medical Society (Kensington, MD).
HBOT prior authorizations will be issued by DHS or its designated vendor. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting prior authorization. All hyperbaric oxygen therapy will require prior authorization, except in emergency cases such as for air embolism or carbon monoxide poisoning, in which post-authorization will be allowed per protocol. See Section 242.000. Prior authorization will be issued for a specific number of treatments. Subsequent treatments will require another review and an additional prior authorization. The caller must be able to provide demographic and clinical information to support the medical necessity of treatment. All information that is submitted to acquire the prior authorization must be documented in the beneficiary's medical record. View or print contact information to obtain instructions for submitting the request for prior authorization.
NOTE: When approved, only one authorization will be issued. The prior authorization and the number of approved HBOT treatments must be communicated to the physician provider so that both the facility and physician may claim reimbursement for the number of approved HBOT sessions. Additionally, if more HBOT sessions are required for the same beneficiary, a new prior authorization is required. A new prior authorization number will be assigned for any additional sessions approved. The prior authorization information between the facility and the physician must be reciprocal if the physician acquires the prior authorization.
The following table provides the diagnosis requirements, description of the problem, and number of treatments.
Diagnosis | Description | Number of Treatments |
(View ICD Codes.) | Air or Gas Embolism | 10 |
(View ICD Codes.) | Decompression Sickness | 10 |
(View ICD Codes.) | Carbon Monoxide Poisoning | 5 |
(View ICD Codes.) | Clostridial Myositis and Myonecrosis (Gas Gangrene) | 10 |
(View ICD Codes.) | Crush injuries, compartment syndrome, other acute traumatic peripheral ischemias | 6 |
(View ICD Codes.) | Enhancement of healing in selected problem wounds; diabetic foot ulcers, pressure ulcers, venous stasis ulcers; only in severe and limb or life-threatening wounds that have not responded to other treatments, particularly if ischemia that cannot be corrected by vascular procedures is present | 30 |
(View ICD Codes.) | Intracranial abscess, multiple abscesses, immune compromise, unresponsive | 20 |
(View ICD Codes.) | Necrotizing Soft Tissue Infections, immune compromise | 30 |
(View ICD Codes.) | Refractory osteomyelitis after aggressive surgical debridement | 40 |
(View ICD Codes.) | Delayed Radiation Injury | 60 |
(View ICD Codes.) | Compromised skin grafts and flaps | 20 |
(View ICD Codes.) | Thermal burns >20% TSBA +/or involvement of hands, face, feet or perineum that are deep, partial or full thickness injury | 40 |
(View ICD Codes.) | Compartment syndrome, impending stage fasciotomy not required. | 1 |
(View ICD Codes.) | Problem wounds after primary management | 14 |
Refer to Section 272.404 of this manual for billing instructions.
DHS or its designated vendor performs retrospective reviews of medical records to determine the medical necessity of services paid for by Medicaid. View or print contact information to obtain the DHS or designated vendor retrospective reviews.
Specific guidelines have been developed for retrospective review of occupational, physical and speech-language therapy services furnished to Medicaid beneficiaries under the age of twenty-one (21). These guidelines are included in this manual to assist providers in determining and documenting the medical necessity of occupational, physical and speech-language therapy services and are found in Sections 218.100 through 218.110
View or print contact information to obtain the DHS or designated vendor step-by-step process for extended therapy services review.
A request for administrative reconsideration of the denial of services must be in writing and sent to DHS or its designated vendor within thirty (30) calendar days of the denial. The request must include a copy of the denial letter and additional supporting documentation.
The deadline for receipt of the reconsideration request will be enforced pursuant to Sections 190.012 and 190.013 of the manual. A request received within thirty-five (35) calendar days of a denial will be deemed timely
There are certain medical, diagnostic and surgical procedures that are not covered without prior authorization, either because of federal requirements or because of the elective nature of a procedure. DHS or its designated vendor makes prior authorization (PA) determinations for most Medicaid-covered surgical procedures that require PA, and for some lab procedures that require PA.
Please refer to Section 244.000 of this manual for a list of procedures requiring prior authorization.
Prior authorization determinations are made utilizing established medical or administrative criteria combined with the professional judgment of physician advisors.
View or print contact information to obtain the DHS or designated vendor step-by-step process for prior authorization.
If surgery is involved, a copy of the authorization will be sent to the hospital where the service will be performed. If the hospital has not received a copy of the authorization before the time of admission, the hospital will contact the admitting physician or DHS or its designated vendor to verify that prior authorization has been granted.
It is the responsibility of the primary surgeon to distribute a copy of the authorization to the assistant surgeon if the assistant has been requested and approved.
Prior authorization of service does not guarantee eligibility for a beneficiary. Coverage is contingent on the beneficiary's eligibility on the date(s) of service.
Post-authorization will be granted only for emergency procedures or retroactively eligible beneficiaries.
FORM DMS-2606 MUST BE ATTACHED TO THE CLAIM FOR PAYMENT.
The document must be reviewed and approved by the Medicaid Program before payment will be considered. All guidelines must be met in order for payment to be made.
Providers performing surgical procedures that require prior authorization are allowed sixty 60 days from the date of service to obtain prior authorization if the beneficiary is under age twenty-one (21).
All requests for post-procedural authorizations for eligible beneficiaries are to be made to DHS or its designated vendor within sixty (60) days of the date of service. These calls will be tape-recorded. View or print contact information to obtain the DHS or designated vendor step-by-step process for extension of benefits review.
The beneficiary and provider identifying criteria and all of the medical data necessary to justify the procedures must be provided.
Consulting physicians are responsible for contacting DHS or its designated vendor to have procedures added to the PA file. Providers must obtain prior authorization for procedures requiring authorization in order to prevent risk of denial due to lack of medical necessity.
This policy applies only to those Medicaid beneficiaries under age twenty-one (21). This policy does not alter prior authorization procedures applicable to retroactive eligible beneficiaries.
The attending physician is responsible for obtaining prior approval for organ transplants.
All hyperbaric oxygen therapy will require prior authorization, except in emergency cases such as for air embolism or carbon monoxide poisoning, in which post-authorization will be allowed per protocol. See Section 242.000. Prior authorization will be for a certain number of treatments. Further treatments will require reapplication for a prior authorization. In order to request a prior authorization for HBOT, the provider must contact DHS or its designated vendor. View or print contact information to obtain instructions for submitting the prior authorization request.
Refer to Sections 217.130, 242.000, 252.119, and 272.404 for additional information on HBOT.
Molecular Pathology procedure codes require prior authorization (PA). Providers must receive prior authorization before a claim for molecular pathology is filed for payment. Providers may request the PA from DHS or its designated vendor before or after the procedure is performed as long as it is acquired in time to receive approval and file a clean claim within the 365-day claims filing deadline. View or print contact information to obtain the DHS or designated vendor step-by-step process to request prior authorization.
Molecular Pathology PA requests must be submitted by the performing provider with submission of a completed Arkansas Medicaid Request for Molecular Pathology Laboratory Services (form DMS-841) and all pertinent clinical documentation needed to justify the procedure.
Reconsideration of denied requests is allowed if new or additional information is received within thirty (30) days of the initial denial. View or print form DMS-841. This form may be found in Section V of the provider manual. Do not complete the form unless you are submitting a Molecular Pathology PA request.
Molecular Pathology procedure codes must be submitted on a red line paper claim form with the PA number listed on the claim and the itemized invoice attached that supports the charges for the test billed. See Section 244.000 for Molecular Pathology procedure codes.
Hyperalimentation fluids, equipment and supplies must be prior authorized by the Department of Human Services (DHS) or its designated vendor. View or print contact information to obtain the DHS or its designated vendor step-by-step process for requesting prior authorization.
Requests for prior authorization originate with the provider. The provider is responsible for obtaining the required medical information and necessary prescription information needed for completion of the Request for Prior Authorization and Prescription Form. View or print form DMS-2615 and instructions for completion. This form must be signed and dated by the prescribing physician.
The request for prior authorization will be reviewed by the Department of Human Services (DHS) or its designated vendor. The documentation submitted with the prior authorization request must support the medical necessity of the requested nutritional therapy. In some cases, additional information may be requested (i.e., original prescription, records from the hospitalization initiating nutritional therapy, nutritional assessment to establish medical necessity for nutritional therapy, etc.).
When the PA request is approved, a prior authorization control number will be assigned. Prior authorization approvals are authorized for a maximum of six (6) months (180 days) or for the life of the prescription, whichever is shorter. If the prescribing physician documents the beneficiary's condition is chronic and unlikely to change, a prior approval may be authorized for a maximum of twelve (12) months. The effective date of the prior authorization will be the date the patient will begin therapy or the day following the last day of the previous authorization approval.
When an eligible Medicaid beneficiary is discharged from the inpatient setting with the continuation of hyperalimentation services in the home, a provider may request a pre-approval for hyperalimentation before the anticipated discharge date. View or print contact information to obtain the DHS or its designated vendor step-by-step process for requesting preapproval for hyperalimentation.
When approved, a prior authorization number will be assigned and will be effective for thirty (30) days. The provider must not bill for hyperalimentation services prior to the date of discharge or bill for services on the same dates of service as the inpatient stay.
If the beneficiary is not discharged within the thirty (30) days, the pre-approval will be void.
When continuation of the therapy is required past the initial thirty (30) day pre-approval, the provider must submit a recertification for prior authorization request with a prescription signed by the prescribing physician, prior to the end date of the pre-approval.
A pre-approval of hyperalimentation services does not guarantee payment.
Medicaid covers prescription drugs in accordance with policies and regulations set forth in this section and pursuant to orders (prescriptions) from authorized prescribers. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) which was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. A numeric listing of approved pharmaceutical companies and their respective labeler codes is located on the Arkansas Division of Medical Services (DMS) Pharmacy website. View or print numeric listing of approved pharmaceutical companies and their respective labeler codes. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with listed labeler codes.
An advanced nurse practitioner with prescriptive authority (verified by the Certificate of Prescriptive Authority Number issued by the licensing authority of the state in which services are furnished) may only prescribe legend drugs and controlled substances identified in the state licensing rules and regulations. Medicaid reimbursement will be limited to prescriptions for drugs in these schedules.
Prescribers must obtain the latest information regarding prescription drug coverage at the website listed in the contact information for DHS or its designated Pharmacy Vendor. View or print contact information for the DHS designated Pharmacy Vendor.
DHS or its designated vendor also completes post-payment reviews of hospital stays for medical necessity determinations. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting extension of inpatient stays.
The Medicaid Program's laboratory and X-ray services benefit limits apply to outpatient laboratory services, radiology services and machine tests.
*OB ultrasounds and fetal non-stress tests are benefit limited. See Section 214.630 for additional coverage information.
The Medicaid Utilization Management Program (MUMP) determines covered lengths of stay in inpatient acute care and/or general hospitals, in state and out of state.
Length-of-stay determinations are made by the Quality Improvement Organization (QIO), under contract to the Arkansas Medicaid Program.
Individuals in all Medicaid eligibility categories and all age groups, except beneficiaries under age one (1), are subject to this policy. Medicaid beneficiaries under age one (1) at the time of admission are exempt from the MUMP policy for dates of service before their first birthday.
Refer to item "E" below for the procedure to follow when a child's first birthday occurs during an inpatient stay.
The procedures for the MUMP are as follows:
View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting extension of inpatient stays.
If the retroactive eligible beneficiary is not identified until after discharge, and the hospital files a claim and receives a denial for any days past the original four allowed, the hospital may request post-extension evaluation approval of the denied days. If granted, the claim may be refiled. If the length of stay is more than thirty (30) days, the provider shall submit the entire medical record to DHS or its designated vendor for review.
Upon receipt of the denial copy and the provider request, a coordinator will call the provider and obtain certification information.
Requests for extension of benefits for Clinical Services (Physician's visits, Nurse Practitioner visits), Outpatient Services (Hospital Outpatient visits), Laboratory Services (Lab Tests) and X-ray services (X-ray, Ultrasound, Electronic Monitoring - e.e.g.; e.k.g.; etc.), must be submitted to DHS or designated vendor for consideration. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting extension of benefits.
Consideration of requests for extension of benefits requires correct completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray (form DMS-671). View or print form DMS-671.
Complete instructions for accurate completion of form DMS-671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each provider manual.
Post-procedural authorization will be granted only for emergency procedures for beneficiaries age twenty-one (21) and older. Requests for post-authorization of an emergency procedure must be applied for on the first working day after the procedure is performed.
In cases of retroactive eligibility, the provider must contact DHS or its designated vendor for post-authorization within sixty (60) days of the eligibility authorization date displayed in the electronic eligibility verification response.
Providers must obtain prior authorization for procedures requiring authorization in order to prevent risk of denial due to lack of medical necessity.
Prescription drugs are available for reimbursement under the Arkansas Medicaid Program when prescribed by a nurse practitioner with prescriptive authority. Certain prescription drugs may require prior authorization. It is the responsibility of the prescriber to request and obtain the prior authorization. Information may be obtained from DHS or its designated vendor. View or print contact information to obtain the DHS or designated vendor prescription drug information.
The following information is available:
The following Molecular Pathology codes require prior authorization from DHS or its designated vendor. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting prior authorization.
81161 | 81200 | 81201 | 81202 | 81203 | 81205 | 81206 | 81207 |
81208 | 81209 | 81210 | 81211 | 81212 | 81213 | 81214 | 81215 |
81216 | 81217 | 81220 | 81221 | 81222 | 81223 | 81224 | 81225 |
81226 | 81227 | 81228 | 81229 | 81235 | 81240 | 81241 | 81242 |
81243 | 81244 | 81245 | 81250 | 81251 | 81252 | 81253 | 81254 |
81255 | 81256 | 81257 | 81260 | 81261 | 81262 | 81263 | 81264 |
81265 | 81266 | 81267 | 81268 | 81270 | 81275 | 81280 | 81281 |
81282 | 81290 | 81291 | 81292 | 81293 | 81294 | 81295 | 81296 |
81297 | 81298 | 81299 | 81300 | 81301 | 81302 | 81303 | 81304 |
81310 | 81315 | 81316 | 81317 | 81318 | 81319 | 81321 | 81322 |
81323 | 81324 | 81325 | 81326 | 81330 | 81331 | 81332 | 81340 |
81341 | 81342 | 81350 | 81355 | 81370 | 81371 | 81372 | 81373 |
81374 | 81375 | 81376 | 81377 | 81378 | 81379 | 81380 | 81381 |
81382 | 81383 | 81400 | 81401 | 81402 | 81403 | 81404 | 81405 |
81406 | 81407 | 81408 |
The American Dental Association (ADA) procedure code D1206 is covered by the Arkansas Medicaid Program. This code is payable for beneficiaries under the age of twenty-one (21). Topical fluoride varnish application benefit is covered every six (6) months plus one (1) day for beneficiaries under age twenty-one (21).
A new specialty code, FC-Fluoride Certification will be tied to provider types 01, 03, 58 and 69. These providers must send proof of their fluoride varnish certification to DHS or its designated vendor before the specialty code will be added to their file in the MMIS. View or print contact information to obtain the DHS or designated vendor step-by-step process for provider enrollment. After the specialty code, FC-Fluoride Certification, is added to the provider's file, the provider will be able to bill for procedure code D1206, Topical Application of Fluoride Varnish.
Providers must check the Supplemental Eligibility Screen to verify that topical fluoride varnish benefit of two (2) per State Fiscal Year (SFY) has not been exhausted. If further treatment is needed due to severe periodontal disease, then the beneficiary must be referred to a Medicaid dental provider.
NOTE: This service is billed on form CMS-1500 with ADA procedure code D1206 (Topical application of fluoride varnish (prophylaxis not included) - child (ages 0-20)).
View a form CMS-1500 sample form.
Nurse practitioners shall administer injections, therapeutic and diagnostic agents in accordance with the rules set forth in the Arkansas Medicaid Physician's policy manual and within the scope of their practice guidelines.
Attributed beneficiaries | The Medicaid beneficiaries for whom primary care physicians and participating practices have accountability under the PCMH program. A primary care physician's attributed beneficiaries are determined by the ConnectCare Primary Care Case Management (PCCM) program. Attributed beneficiaries do not include dual eligible beneficiaries. |
Attribution | The methodology by which Medicaid determines beneficiaries for whom a participating practice may receive practice support and incentive payments. |
Care coordination | The ongoing work of engaging beneficiaries and organizing their care needs across providers and care settings. |
Care coordination payment | Quarterly payments made to participating practices to support care coordination services. Payment amount is calculated per attributed beneficiary, per month. |
Default pool | A pool of beneficiaries who are attributed to participating practices that do not meet the requirements in Section 233.000, part A or part B. |
Medical neighborhood barriers | Obstacles to the delivery of coordinated care that exist in areas of the health system external to PCMH. |
Participating practice | A physician practice that is enrolled in the PCMH program, which must be one of the following: A. An individual primary care physician (Provider Type 01 or 03); B. A physician group of primary care providers who are affiliated, with a common group identification number (Provider Type 02, 04 or 81); C. A Rural Health Clinic (Provider Type 29) as defined in the Rural Health Clinic Provider Manual Section 201.000; or D. An Area Health Education Center (Provider type 69). |
Patient-Centered Medical Home (PCMH) | A team-based care delivery model led by Primary Care Physicians (PCPs) who comprehensively manage beneficiaries' health needs with an emphasis on health care value. |
Performance adjustment | An adjustment to the cost of beneficiary care to account for patient risk. |
Performance period | The period of time over which performance is aggregated and assessed. |
Petite pool | Pool reserved for practices with less than 300 attributed beneficiaries that do not wish to participate in a voluntary pool. |
Pool | A. The beneficiaries who are attributed to one or more participating practice(s) for the purpose of forming a shared performance entity; or |
B. The action of aggregating beneficiaries for the purposes of performance-based incentive payment calculations (i.e., the action of forming a shared performance entity). | |
Practice support | Support provided by Medicaid in the form of care coordination payments to a participating practice. |
Practice transformation | The adoption, implementation and maintenance of approaches, activities, capabilities and tools that enable a participating practice to serve as a PCMH. |
Primary Care Physician (PCP) | See Section 171.000 of the Arkansas Medicaid provider manual. |
Provider portal | The website that participating practices use for purposes of enrollment, reporting to the Division of Medical Services (DMS) and receiving information from DMS. |
Quality Improvement Plan (QIP) | QIP is a plan of improvement that practices must submit to PCMH Quality Assurance team after receiving notice of attestation failure or validation failure. |
Recover | To deduct an amount from a participating practice's future Medicaid receivables, including without limitation, PCMH payments, or fee-for-service reimbursements, to recoup such amount through legal process, or both. |
Remediation time | The period during which participating practices that fail to meet deadlines, targets or both on relevant activities and metrics tracked for practice support may continue to receive care coordination payments while improving performance. |
Same-day appointment request | A beneficiary request to be seen by a clinician within 24 hours. |
Shared performance entity | A PCMH or pooled PCMHs that, contingent on performance, may receive performance-based incentive payments. |
State Health Alliance for Records Exchange (SHARE) | The Arkansas Health Information Exchange. For more information, go to SHARE. |
Enrollment in the PCMH program is voluntary and practices must re-enroll annually. To enroll, practices must access the Advanced Health Information Network (AHIN) provider portaland submit a complete and accurate Arkansas Medicaid Patient-Centered Medical Home Practice Participation Agreement (DMS-844).
Once enrolled, a participating PCMH remains in the PCMH program until:
A physician may be affiliated with only one participating practice. A participating practice must update the Department of Human Services (DHS) on changes to the list of physicians who are part of the practice. Physicians who are no longer participating with a practice are required to update in writing via email with the Fiscal Contractorwithin thirty (30) days of the change.
All practice site locations associated with a PCMH must be listed on the PCMH Program enrollment application. Each site listed on the enrollment application must complete practice support requirements as described in Section 241.000. If a site does not meet deadlines and targets for activities tracked for practice support, then the site must remediate its performance to avoid suspension or termination of practice support for the entire PCMH.
To withdraw from the PCMH program, the participating practice must email a complete and accurate Arkansas Patient-Centered Medical Home Withdrawal Form (DMS-846) to the Fiscal Contractor. View or print the Arkansas Patient-Centered Medical Home Withdrawal Form (DMS-846) on the APII website. or download the form from the AHIN provider portal.
A practice may return to the PCMH Program beginning on the first day of the following performance year (January 1st) after suspension or termination of practice support. Such application for reinstatement is contingent on documentation of successful implementation of all previously deficient requirements and upon meeting the following requirements:
Practices who withdraw while on remediation will also have to meet the re-instatement requirements. Successful implementation of the activity(s) will be determined by the Quality Assurance Team.
PCMHs may voluntarily pool for purposes described in Section 233.000 before the end of the enrollment period that precedes the start of the performance period. To pool, the participating practice must email a complete and accurate Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Form (DMS-845) to the Fiscal Contractor. View or print the Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Form on the APII website. You can also download the form from the AHIN provider portal.
The DMS-845 Pooling form must be executed by all PCMHs participating in the pool. Before the end of the enrollment period, PCMHs that are on their own or through pooling do not reach a minimum of 1,000 attributed beneficiaries will be assigned to the default pool. Practices with less than 300 attributed beneficiaries that do not wish to participate in a voluntary pool will be placed in the petite pool. Individual PCMHs whose attribution changes during the performance period will be classified as standalone, default, or petite pool members according to their attribution count at the end of the performance period.
Pooling is effective for a single performance period and must be renewed for each subsequent year.
When a PCMH has voluntarily pooled, its performance is measured in the associated shared performance entity throughout the duration of the performance period unless it withdraws from the PCMH program during the performance period. When a PCMH in a voluntary pool withdraws, is suspended, or otherwise leaves the PCMH program, any and all PCMHs in the shared performance entity will have their performance measured as if the withdrawn or suspended PCMH had never participated in the pool. This provision does not apply to PCMHs that leave the program in the last calendar quarter. If the PCMH leaves the program in the last calendar quarter, the departing PCMH, and its performance will be treated as if the PCMH has not left the program.
The following excluded drugs are set forth on the DHS Contracted Pharmacy Vendor website.
Each prescription filled counts toward the monthly prescription limit except for the following:
Prescriptions for Medicaid-eligible LTC facility residents are not subject to a monthly prescription limit; however, the drug product must be covered under the Arkansas Medicaid Pharmacy Program. Information is available from DHS or its contracted Pharmacy Vendor. View or print the DHS Contracted Pharmacy Vendor Help Desk contact information.
Due to the importance of maintaining accurate prices in the drug master file, it is necessary that drug companies keep various drug pricing contractors informed of all product and price revisions. The Arkansas Medicaid Program's fiscal agent contracts with a national compendia to provide pricing information. It is the pharmacists' responsibility to contact the DHS contracted Pharmacy Vendor's Help Desk to determine if a manufacturer's products are listed in the national compendia drug file. View or print the DHS Contracted Pharmacy Vendor Help Desk contact information.
Prescription drugs may be reimbursed under the Arkansas Medicaid Program pursuant to an order from an authorized prescriber.
The prescriber must initiate the prior authorization (PA) for prescription drugs that require PA. The PA request must be completed and submitted by the prescriber. All PA documentation must remain in the patient's chart and will be subject to audit by the Division of Medical Services or its authorized representatives.
In addition, clinical edits will be established through a system modification enhancement, as well as limits placed on drugs based on age, gender, quantity and dosage, as approved by our Drug Utilization Review Board. Lists of all drugs subject to clinical editing and the criteria for reimbursement are maintained by DHS or its contracted Pharmacy Vendor View or print the DHS Contracted Pharmacy Vendor Help Desk contact information.
Arkansas Medicaid Pharmacy Program will maintain a Preferred Drug List based on comparative evidence-based data from Clinical Evidence Reports (CER). Arkansas Medicaid Pharmacy Program will use the CER to identify drug class or drug classes of medications that have similar indications, efficacy, and safety. Arkansas Medicaid will negotiate state supplemental rebates with manufacturers for the identified medication(s) pursuant to a CMS approved State Supplemental Rebate Agreement. A Drug Cost Committee (DCC) will review both State Supplemental and Federal rebates to determine the final net cost to the State of the identified medication(s). A Drug Review Committee (DRC) will review the CER to determine safety and efficacy of the identified medication(s). The DCC and DRC will provide recommendations to the State for preferred and non-preferred status for the identified medication(s). Arkansas Medicaid will use these recommendations to establish and maintain a Preferred Drug List.
In an emergency, for those drugs for which a five-day supply can be dispensed, an Arkansas Medicaid enrolled pharmacy may dispense up to a five-day supply of a drug that requires prior authorization. This provision applies only in an emergency situation when the DHS Contracted Pharmacy Vendor Help Desk and the State Medicaid Pharmacy Program offices are closed, and the pharmacist is not able to contact the prescribing provider to change the prescription. The Emergency Supply Policy does not apply to drugs that are not covered by the State. Frequency of the emergency override is limited to once per year per drug class for non-LTC beneficiaries and once per sixty (60) days per drug class for LTC beneficiaries. To file a claim using this emergency provision, the pharmacy provider will submit a "03" in the Level of Service (418-DI) field.
Prior Authorization information is maintained by DHS or its contracted Pharmacy Vendor. View or print the DHS Contracted Pharmacy Vendor Help Desk contact information.
The following information is available:
The prescriber must determine whether the Medicaid beneficiary meets the required conditions to override an Upper Limit (FUL, SAAC, Generic NADAC). The prescriber must also complete the required MedWatch (see below) documentation to allow a prior authorization (PA) for a "Brand Medically Necessary" override of the Upper Limit to reimburse at the brand name reimbursement rate.
MedWatch is the Food and Drug Administration (FDA) Safety Information and Adverse Event Reporting Program that allows healthcare professionals to report serious problems that they suspect are associated with certain drugs they prescribe.
The following criteria must be met to override the Upper Limit when calculating the allowable amount of reimbursement:
In the context of this policy, "Brand Medically Necessary" is defined as the necessity to prescribe and dispense a brand name medication when use of a generic product has resulted in adverse reaction(s) to the generic, allergic reaction(s) to the generic or therapeutic failure of the generic.
The PA is given for up to one year for MedWatch Drugs.
All prescriptions must be on file for review by auditors from the Division of Medical Services or their designated agents.
If the criteria stated above are met and the pharmacy claim is submitted with a code of "1" in the dispense as written (DAW) field, the prescription will be priced using the Brand NADAC (or WAC when applicable) for the specific product dispensed rather than the Upper Limit rate.
DHS or its designated vendor also completes post-payment reviews of hospital stays of any length for medical necessity determinations. View or print DHS or designated vendor contact information to obtain MUMP information.
Medicaid covers prescription drugs in accordance with policies and regulations set forth in this section and pursuant to orders (prescriptions) from authorized prescribers. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. A numeric listing of approved pharmaceutical companies and their respective labeler codes is located on the DHS or designated pharmacy vendor website. View or print numeric listing of approved pharmaceutical companies and their respective labeler codes. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with listed labeler codes.
Prescribers must obtain the latest information regarding prescription drug coverage from the DHS contracted Pharmacy Vendors website. View or print DHS contracted Pharmacy vendor contact information.
Benefit limits are the limits on the quantity of covered services Medicaid-eligible beneficiaries may receive. Medicaid-eligible beneficiaries are responsible for payment for services beyond the established benefit limits, unless the Division of Medical Services (DMS) authorizes an extension of a particular benefit.
If a service is denied for exceeding the benefit limit, and the Medicaid beneficiary had elected to receive the service by written informed consent prior to the delivery of the service, the Medicaid beneficiary is responsible for the payment, unless that service has been deemed not medically necessary.
Benefit extensions are considered after the service has been rendered and the provider has received a denial for "benefits exhausted." DMS considers requests for benefit extensions based on the medical necessity of the service. If a Medicaid provider chooses to file for an extension of benefits and is denied due to the service not being medically necessary, the beneficiary is not responsible for the payment. Once the extension of benefits request has been initiated on a specific service, the provider cannot abort the process before a final decision is rendered.
Please see Section 229.000 through Section 229.120 and Section 131.000 points A and C for benefit extension request procedures. DMS reviews extension of benefits requests for Home Health, personal care, diapers and medical supplies. DHS or its designated vendor reviews extension of benefits requests for physician, lab, radiology and machine tests, using form DMS-671. All personal care services for beneficiaries under age 21 are reviewed by the contracted Quality Improvement Organization (QIO). View or print contact information for DHS or its designated vendor regarding benefit limits.
The Medicaid Utilization Management Program (MUMP) determines covered lengths of stay in inpatient, general and rehabilitative hospitals, in state and out-of-state. The MUMP does not apply to lengths of stay in psychiatric facilities.
Length-of-stay determinations are made by DHS or the Quality Improvement Organization (QIO), under contract to the Arkansas Medicaid Program.
Calls for extension of days may be made at any time during the inpatient stay (except in the case of a transfer from another hospital - refer to Section 224.320).
Providers initiating their request after the fourth day must accept the financial liability should the stay not meet the necessary medical criteria for inpatient services. If the provider delays calling for extension verification and the services are denied based on medical necessity, the beneficiary may not be held liable.
If a patient is transferred from one hospital to another, the receiving facility must contact DHS or its designated vendor within twenty-four (24) hours of admitting the patient to certify the inpatient stay. View or print contact information to obtain the DHS or designated vendor step-by-step process to request certification.
Reconsideration reviews of denied extensions may be requested by sending the medical record to DHS or its designated vendor. The hospital will be advised of the reconsideration decision by the next working day.
View or print contact information to obtain the DHS or designated vendor step-by-step process for reconsideration requests.
Requests for extension of benefits for Clinical Services (Physician's Visits), Outpatient Services (Hospital Outpatient visits), Laboratory Services (Lab Tests) and X-ray services (X-ray, Ultrasound, Electronic Monitoring - e.e.g.; e.k.g.; etc-), must be submitted to DHS or its designated vendor for consideration. View or print contact information to obtain the DHS or designated vendor step-by-step process to complete request. Consideration of requests for extension of benefits requires correct completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray (form DMS-671). View or print form DMS-671.
Instructions for accurate completion of form DMS-671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each Provider Manual.
View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting extended therapy services.
A request for administrative reconsideration of the denial of services must be in writing and sent to DHS or its designated vendor within thirty (30) calendar days of the denial. The request must include a copy of the denial letter and additional supporting documentation.
The deadline for receipt of the reconsideration request will be enforced pursuant to Sections 190.012 and 190.013 of the Arkansas Medicaid manual. A request received by DHS or its designated vendor within thirty-five (35) calendar days of a denial will be deemed timely.
For medical payment to be made to an assistant surgeon, the physician who wishes to use an assistant surgeon must obtain prior authorization from the DHS or its designated vendor. Assistant surgeon services are reimbursed only when provided by a physician. See Section 261.000 of this manual for prior authorization instructions. This provision applies to all surgery.
Only medically necessary abortions are covered by Arkansas Medicaid. Federal regulations prohibit expenditures for abortions except when the life of the mother would be endangered if the fetus were carried to term or for victims of rape or incest, defined under Ark. § Code Ann. 5-14103 and § 5-22-202, as certified in writing by the woman's attending physician.
View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting a review.
01966 | 59840 | 59841 | 59850 |
59851 | 59852 | 59855 | 59856 |
59857 |
The Arkansas Medicaid Program provides coverage for cochlear implantation and the external sound processor for beneficiaries under age twenty-one (21) in the Child Health Services (EPSDT) Program. (See Section 261.120 for prior authorization requirements and Section 292.801 for billing protocol.)
Cochlear Implants are covered through the Arkansas Medicaid Physician or Prosthetics Program for eligible Medicaid beneficiaries under the age of twenty-one (21) years through the Child Health Services (EPSDT) Program when prescribed by a physician.
The cochlear implant device, implantation procedure, the sound processor and other necessary devices for use with the cochlear implant device require prior authorization from DHS or its designated vendor. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting prior authorization.
The replacements of lost, stolen or damaged external components (not covered under the manufacturer's warranty) are covered when prior authorized by Arkansas Medicaid.
Reimbursements for manufacturer's upgrades will not be made. An upgrade of a speech processor to achieve aesthetic improvement, such as smaller profile components or a switch from a body worn, external sound processor to a behind-the-ear (BTE) model or technological advances in hardware, are considered not medically necessary and will not be approved.
2010 Codes | Modifier | Age Restriction | Manually Priced | Review | PA |
L8627* | EP | 0-20 | Yes | No | Yes |
L8628 * | EP | 0-20 | Yes | No | Yes |
L8629* | EP | 0-20 | Yes | No | Yes |
*Denotes paper claim required
Arkansas Medicaid will not cover new generation speech processors if the existing one is still functional. Consideration of the replacement of the external speech processor will be made only in the following instances:
Additional medical documentation supporting medical necessity for replacement of external components should be attached to any requests for prior authorization.
Arkansas Medicaid will reimburse for a personal FM system for use by a cochlear implant beneficiary when prior authorized and not available by any other source (i.e., educational services). The federal Individuals with Disabilities Education Act (IDEA) requires public school systems to provide FM systems for educational purposes for students starting at age three (3). Arkansas Medicaid does not cover FM systems for children who are eligible for this service through IDEA.
A Request for Prior Authorization may be submitted for medically necessary FM systems (procedure code V5273 for use with cochlear implant) that are not covered through IDEA; each request must be submitted with documentation of medical necessity. These requests will be reviewed on an individual basis.
The repair and/or replacement of the cochlear implant external speech processor and other supplies (including batteries, cords, battery charger and headsets) will be covered in accordance with the Arkansas Medicaid policy for the Physician and Prosthetics programs. The covered services must be billed by an Arkansas Medicaid Physician or Prosthetics provider. The supplier is required to request prior authorization for repairs or replacements of external implant parts.
View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting prior authorization.
Tobacco cessation products either prescribed or initiated through statewide pharmacist protocol are available without prior authorization (PA) to eligible Medicaid beneficiaries. Additional information can be found on the designated Pharmacy Vendor websiteor in the Prescription Drug Program Prior Authorization Criteria.
Physicians may be reimbursed for attendance and supervision of hyperbaric oxygen therapy.
Hyperbaric oxygen therapy (HBOT) involves exposing the body to oxygen under pressure greater than one atmosphere. Such therapy is performed in specially constructed hyperbaric chambers holding one (1) or more patients; although oxygen may be administered in addition to the hyperbaric treatment. Patients should be assessed for contraindications such as sinus disease or claustrophobia prior to therapy. In some diagnoses, hyperbaric oxygen therapy (HBOT) is only an adjunct to standard surgical therapy. These indications are taken from "The Hyperbaric Oxygen Therapy Committee Report" (2003) of The Undersea and Hyperbaric Medical Society (Kensington, MD).
Hyperbaric oxygen therapy (HBOT) prior authorizations will be issued by DHS or its designated vendor. All hyperbaric oxygen therapy (HBOT) will require prior authorization, except in emergency cases such as for air embolism or carbon monoxide poisoning, in which case, post authorization will be allowed per protocol (See Section 261.100). Prior authorization will be for a specific number of treatments. Further treatments will require reapplication for a prior authorization. View or print contact information to obtain the DHS or designated vendor step-by-step process for HBOT prior authorization requests.
NOTE: When approved, only one authorization will be issued. The prior authorization and the number of approved HBOT treatments must be shared with the facility provider so that both the physician and the facility may be reimbursed for the number of approved HBOT sessions. Additionally, if more HBOT sessions are required, a new prior authorization must be requested and the above process followed. A new prior authorization will be assigned for any additional sessions approved. The prior authorization information between the physician and the facility shall be reciprocal if the facility acquires the prior authorization.
The following table provides the diagnosis requirements, description of the problem, and number of treatments.
Diagnosis | Description | Number of Treatments |
View ICD Codes. | Air or Gas Embolism | 10 |
View ICD Codes. | Decompression Sickness | 10 |
View ICD Codes. | Carbon Monoxide Poisoning | 5 |
View ICD Codes. | Clostridial Myositis and Myonecrosis (Gas Gangrene) | 10 |
View ICD Codes. | Crush injuries, compartment syndrome, other acute traumatic peripheral ischemias | 6 |
View ICD Codes. | Enhancement of healing in selected problem wounds; diabetic foot ulcers, pressure ulcers, venous stasis ulcers; only in severe and limb or lifethreatening wounds that have not responded to other treatments, particularly if ischemia that cannot be corrected by vascular procedures is present | 30 |
View ICD Codes. | Intracranial abscess, multiple abscesses, immune compromise, unresponsive | 20 |
View ICD Codes. | Necrotizing Soft Tissue Infections, immune compromise | 30 |
View ICD Codes. | Refractory osteomyelitis after aggressive surgical debridement | 40 |
View ICD Codes. | Delayed Radiation Injury | 60 |
View ICD Codes. | Compromised skin grafts and flaps | 20 |
View ICD Codes. | Thermal burns > 20% TSBA +/or involvement of hands, face, feet or perineum that are deep, partial or full thickness injury | 40 |
View ICD Codes. | Compartment syndrome, impending stage fasclotomy not required | 1 |
View ICD Codes. | Problem wounds after primary management | 14 |
Refer to Section 292.860 of this manual for billing instructions.
Certain medical and surgical procedures are covered only with prior authorization (PA). Refer to sections 261.100 through 261.220 for instructions on requesting PA.
(IF REQUEST IS MADE BY PHONE, ALL CALLS WILL BE TAPE RECORDED)
View or print Medicaid Utilization Review contact information.
This policy applies only to those eligible Medicaid beneficiaries under age twenty-one (21). This policy does not alter policy currently applicable to retroactive-eligible beneficiaries.
View or print form DMS-679 and instructions for completion. The original and first copy of the form 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 prior authorization requests.
Physician services relating to other covered transplant surgery procedures will be reimbursed at the lesser of negotiated rates or 80% of billed charges, subject to subsequent review to determine that only covered charges are reimbursed.
Abortion procedures performed when the life of the mother would be endangered if the fetus were carried to term require prior authorization from DHS or its designated vendor.
Abortion for pregnancy resulting from rape or incest must be prior authorized by the Division of Medical Services, Administrator, and Utilization Review.
The physician must request prior authorization for the abortion procedures and for anesthesia. Refer to Section 260.000 of this manual for prior authorization procedures. The physician is responsible for providing the required documentation to other providers (hospitals, anesthetist, etc.) for billing purposes.
All claims must be made on paper with attached documentation. A completed Certification Statement for Abortion (form DMS-2698 Rev. 8/04), patient history and physical are required for processing of claims.
Use the following procedure codes when billing for abortions.
01966 | 59840 | 59841 | 59850 | 59851 | 59852 |
59855 | 59856 | 59857 |
Refer to Section 251.220 of this manual for policies and procedures regarding coverage of abortions and Sections 261.000, 261.100, 261.200, 261.260 for prior authorization instructions.
The American Dental Association (ADA) procedure code D1206 is covered by the Arkansas Medicaid Program. This code is payable for beneficiaries under the age of twenty-one (21). Topical fluoride varnish application benefit is covered every six (6) months plus (1) day for beneficiaries under age twenty-one (21).
A new specialty code, FC-Fluoride Certification will be tied to provider types 01, 03, 58 and 69. These providers must send proof of their fluoride varnish certification to Provider Enrollment before the specialty code will be added to their file in the MMIS. After the specialty code, FC-Fluoride Certification, is added to the provider's file, the provider will be able to bill for procedure code D1206, Topical Application of Fluoride Varnish.
Providers must check the Supplemental Eligibility Screen to verify that topical fluoride varnish benefit of two (2) per State Fiscal Year (SFY) has not been exhausted. If further treatment is needed due to severe periodontal disease, then the beneficiary must be referred to a Medicaid dental provider.
NOTE: This service is billed on form CMS-1500 with ADA procedure code D1206 (Topical application of fluoride varnish (prophylaxis not included) - child (ages 0-20). View a CMS-1500 sample form.
Molecular Pathology procedure codes, including Healthcare Common Procedural Coding System Level II (HCPCS) procedure code G0452 requires prior authorization (PA). Providers must receive prior authorization before a claim for molecular pathology is filed for payment. Providers may request the PA from DHS or its designated vendor before or after the procedure is performed as long as it is acquired in time to receive approval and file a clean claim within the 365-day filing deadline. View or print contact information to obtain the DHS or designated vendor step-by-step process for prior authorization requests.
Molecular Pathology PA requests must be submitted by the performing provider with submission of a completed Arkansas Medicaid Request for Molecular Pathology Laboratory services (Form DMS-841) and all pertinent clinical documentation needed to justify the procedure.
Reconsideration of a denied request is allowed if new or additional information is received within thirty (30) days of the initial denial. A copy of the DMS-841 is located in Section V of this provider manual. View or print form DMS-841. Do not complete DMS-841 unless you are submitting a Molecular Pathology Prior Authorization request. Molecular Pathology procedure codes must be submitted on a red line CMS-1500 claim form with the Prior Authorization number listed on the claim form and the itemized invoice attached which supports the charges for the test billed.
Use Healthcare Common Procedural Coding System Level II (HCPCS) procedure code G0452 for coding the Interpretation and Report of 2013 Molecular Pathology codes that allow separate Interpretation and Report. The prior authorization request for G0452 must be submitted with the Arkansas Medicaid Request for Molecular Pathology Laboratory Services (Form DMS-841). Prior authorization for G0452 must be obtained at the same time as the prior authorization for the CPT Molecular Pathology code. The prior authorization request for G0452 must include the CPT Molecular Pathology procedure code for which the Interpretation and Report is to be provided. G0452 must be billed on a red line CMS-1500 paper claim form with CPT Molecular Pathology code(s) specified for which the Interpretation and Report was performed. The claim form should list the prior authorization number. The invoice must be attached that reflects the cost to the provider for performing the interpretation and report of the test.
See Section 262.000 for additional information on Molecular Pathology procedure codes.
Use this method only when either of the following conditions exists:
Bill Medicaid for the antepartum care in accordance with the special billing procedures set forth in Section 292.675. The visits for antepartum care will not be counted against the patient's annual physician benefit limit. Date-of-service spans shall not include any dates for which the patient was ineligible for Medicaid.
Bill Medicaid for the delivery and postpartum care with the applicable procedure code from the following table:
National Codes | |||
59410 | 59515 | 59614 | 59622 |
Non-emergency hysterectomy after C-section requires prior authorization from DHS or its designated vendor. View or print contact information to obtain the DHS or designated vendor step-by-step process for prior authorization requests. Refer to Section 292.580 for billing instructions for emergency and non-emergency hysterectomy after C-section.
If Method 2 is used to bill for OB services, providers must ensure that the services are billed within the 365-day filing deadline.
If only the delivery is performed and neither antepartum nor postpartum services are rendered, procedure codes 59409 or 59612must be billed for vaginal delivery and procedure codes 59514 or 59620 must be billed for cesarean section. Procedure codes 59400, 59410, 59510 and 59515 shall not be billed in addition to procedure codes 59409, 59612, 59514 or 59620. These procedures will be reviewed on a post-payment basis to ensure that these procedures are not billed in addition to antepartum or postpartum care.
Laboratory and X-ray services may be billed separately using the appropriate CPT codes, if this is the physician's standard office practice for billing OB patients. If lab tests or X-rays are pregnancy related, the referring physician must code correctly when these services are sent to the lab or X-ray facility. The diagnostic facilities are totally dependent on the referring physician for diagnosis information necessary for Medicaid reimbursement.
The obstetrical laboratory profile procedure code 80055 consists of four components: Complete Blood Count, VDRL, Rubella and blood typing and RH. If the ASO titer (procedure code 86060) is performed, the test must be billed separately using the individual code.
If a blood specimen is sent to an outside laboratory, only a collection fee may be billed. No additional fees shall be billed for other types of specimens that are sent for testing to an outside laboratory. The outside laboratory may then bill Medicaid for the laboratory procedure. Refer to Section 292.600 of this manual.
NOTE: Payment will not be made for emergency room physician charges on an OB patient admitted directly from the emergency room into the hospital for delivery.
***(.) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the service. When using a procedure code with this symbol, the service must meet the indicated Arkansas Medicaid description.
Current Procedure Code | Current Modifier | Arkansas Medicaid Description |
99406* | SE | *** (Smoking and tobacco use cessation counseling visit; intermediate, 15-minutes) |
99406* | CG | *** (Smoking and tobacco use cessation counseling visit, intermediate, 15-minutes provided to parents of children birth through twenty (20) years of age) |
99407* | SE | *** (Smoking and tobacco use cessation counseling visit; intensive, 30-minutes) |
99407* | CG | *** (Smoking and tobacco use cessation counseling visit, intensive, 30-minutes provided to parents of children birth through twenty (20) years of age) |
* Exempt from PCP referral.
Oral surgeons must use procedure code D9920 for one 15-minute unit and procedure code D1320 for one 30-minute unit when filing claims on the American Dental Association (ADA).
See Section 257.000 of this manual for coverage and benefit limit information.
PRESCRIPTION DRUG INFORMATION
Medicaid covers prescription drugs in accordance with policies and regulations set forth in this section and pursuant to orders (prescriptions) from authorized prescribers in relation to their specialty of practice. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. A numeric listing of approved pharmaceutical companies and their respective labeler codes is located on the DHS or designated pharmacy vendor website. View or print numeric listing of approved pharmaceutical companies and their respective labeler codes. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with listed labeler codes.
The latest information regarding prescription drug coverage is available from DHS or its designated Medicaid Pharmacy vendor. View or print contact information for the DHS contracted Pharmacy Vendor.
Medicaid-eligible patients are responsible for payment for services beyond the established benefit limits, unless DHS or its designated vendor authorizes an extension of a particular benefit. If a Medicaid-eligible patient elects to receive a service for which a benefit extension has been denied or is subsequently denied, the patient is responsible for payment. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting extension of benefits.
View or print contact information to obtain the DHS or designated vendor step-by-step process for extension of benefits review.
There are certain surgical procedures and medical services and procedures that are not reimbursable without prior authorization, either because of federal requirements or because of the nature of the service.
DHS or its designated vendor performs prior authorizations for several medical or surgical procedures. Certain procedures are restricted to the outpatient setting unless prior authorized for inpatient services. Other services may only be billed when performed in a nursing home or skilled nursing facility setting. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting prior authorization.
Section 242.120 contains the list of all procedure codes that require prior authorization.
Prior authorization determinations are made by utilizing established medical or administrative criteria combined with the professional judgment of physician advisors. Payment of services is made to participating providers in accordance with federal regulations.
It is the responsibility of the podiatrist to initiate the prior authorization request. View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting prior authorization.
CPT codes that require prior authorization are located in Section 242.120 of this manual.
It is the responsibility of the primary podiatrist to distribute a copy of the authorization to the anesthesiologist and the assistant podiatrist if the assistant has been requested and approved.
Prior authorization of a service does not guarantee eligibility for a beneficiary. Payment is subject to verification that the beneficiary was eligible at the time the services were provided.
Post-authorization will be granted only for emergency procedures or retroactively eligible beneficiaries. Requests for emergency procedures must be requested on the first working day after the procedure has been performed. In cases of retroactive eligibility, DHS or its designated vendor must be contacted for post-authorization within sixty (60) days of the authorization date. View or print contact information to obtain the DHS or designated vendor step-by-step process for post-authorization.
Requests for extension of benefits for Clinical Services (Physician's Visits), Outpatient Services (Hospital Outpatient visits), Laboratory Services (Lab Tests) and X-ray services (X-ray, Ultrasound, Electronic Monitoring - e.e.g.; e.k.g.; etc-), must be submitted to DHS or its designated vendor. View or print DHS or its designated vendor contact information for extension of benefits for how to obtain information regarding submission processes. AFMC for consideration. Consideration of requests for extension of benefits requires correct completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray (form DMS-671). View or print form DMS-671.
Instructions for accurate completion of form DMS- 671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each Provider Manual.
At least once every six (6) months, the prosthetics provider must receive a prescription for prosthetics services from either the beneficiary's primary care physician or advanced practice registered nurse within the scope of practice and, when applicable:
As necessary, the provider must:
Form DMS-699, titled Request for Extension of Benefits, serves as both a request form and a notification of approval or denial of extension of benefits when requesting diapers and underpads for beneficiaries age three (3) and older. If the benefit extension is approved, the form returned to the provider will contain a Benefit Extension Control Number. The approval notification will also list the procedure codes approved for benefit extension, the approved dates or date-of-service range and the number of units of service (or dollars, when applicable) authorized.
Upon notification of a benefit extension approval, providers may file the benefit extension claims electronically, entering the assigned Benefit Extension Control Number in the Prior Authorization (PA) number field. Subsequent benefit extension requests to the Utilization Review Section will be necessary only when the Benefit Extension Control Number expires or when a beneficiary's need for services unexpectedly exceeds the amount or number of services granted under the benefit extension.
Arkansas Medicaid covers apnea monitors only for infants less than one (1) year of age. Use of the apnea monitor must be medically necessary and prescribed by a physician.
A primary care physician (PCP) is not required until an infant's Medicaid eligibility has been determined. No PCP referral for medical services is required for retroactive eligibility periods.
For the initial certification, the prescribing physician must sign form DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. The physician's signature must be an original, not a stamp. When an apnea monitor is prescribed during a hospital discharge, the physician ordering the apnea monitor must be in consultation with a neonatologist or pulmonologist.
As necessary, the primary care physician's (PCP's) name and provider number must also be indicated on DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. The PCP's signature is not required on the initial certification but he or she must sign all re-certifications.
A prior authorization request for an apnea monitor must be submitted to DHS or its designated vendor on form DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. View or print form DMS-679 and instructions for completion. View or print contact information for how to obtain information regarding submission processes.
Prior authorization is not required for the initial sixty-day period of use of the monitor. If the apnea monitor is needed longer than an initial sixty-day period, prior authorization is required.
A new prescription, documentation of compliance during the initial sixty-day period and proof of medical necessity for the continuation of monitoring are required.
Documentation of compliance and the download monitor report must accompany the request for continued use of the apnea monitor following the initial sixty-day time period.
The following criteria, established by the American Academy of Pediatrics, are to be used to evaluate the need for an apnea monitor after the initial sixty-day period:
The use of home cardiorespiratory monitoring in this population should be limited to approximately forty-three (43) weeks post conceptual age or after the cessation of extreme episodes, whichever comes last.
In many of these cases, the use of pulse oximetry monitoring is superior and preferred over simple cardiorespiratory monitoring.
An ALTE is defined as "an episode that is frightening to the observer and is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking or gagging."
The augmentative communication device (ACD) is covered for beneficiaries of all ages. Coverage for beneficiaries under twenty-one (21) years of age must result from an EPSDT screen. There is a $7,500.00 lifetime benefit for augmentative communication devices. When a beneficiary who is under age twenty-one (21) has met the lifetime benefit and it is determined that additional equipment is medically necessary, the provider may request an extension of benefits by submitting form DMS-679A. View or print form DMS-679A.
The ACD is also covered for Medicaid beneficiaries twenty-one (21) years old and older. Prior authorization is required on the device and on repairs of the device. For beneficiaries who are age twenty-one (21) and above, a $7,500.00 lifetime benefit without benefit extensions applies.
The Arkansas Medicaid Program will not cover ACDs that are prescribed solely for social or educational development.
Training in the use of the device is not included and is not a covered cost.
Prior authorization must be requested for repairs of equipment or associated items after the expiration of the initial maintenance agreement.
Form DMS-679A, titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components serves as a request form when requesting extension of benefits for the augmentative communication device. View or print contact information for how to obtain information regarding submission processes for augmentative communication device.
The form should be accompanied by:
Benefit Limit
Arkansas Medicaid limits augmentative communication devices to a $7500 lifetime benefit. When the beneficiary under age twenty-one (21) has met the limit and it is determined that additional equipment is necessary, the provider may request an extension of benefits. DHS or its designated vendor reviews and determines approval or denial for an extension of the lifetime benefit. View or print contact information for how to obtain information on how to submit the request.
The provider must submit a form DMS-679A, a completed Medicaid claim and medical records substantiating medical necessity that the beneficiary cannot function using his or her existing equipment and whether the equipment can be repaired or needs repair. View or print form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components.
Cochlear implants are covered through the Arkansas Medicaid Physician or Prosthetics Programs for eligible Medicaid beneficiaries under the age of twenty-one (21) years through the Child Health Services (EPSDT) program when prescribed by a physician.
The replacements of lost, stolen or damaged external components (not covered under the manufacturer's warranty) are covered when prior authorized by Arkansas Medicaid.
Reimbursements for manufacturer's upgrades will not be made. An upgrade of a speech processor to achieve aesthetic improvement, such as smaller profile components, or a switch from a body-worn, external sound processor to a behind-the-ear (BTE) model or technological advances in hardware are not considered medically necessary and will not be approved.
Arkansas Medicaid will not cover new generation speech processors if the existing one is still functional. Consideration of the replacement of the external speech processors will be made only in the following instances:
Additional documentation supporting medical necessity for replacement of external components should be attached to any requests for prior authorization.
Arkansas Medicaid will reimburse for a personal FM system for use by a cochlear implant beneficiary when prior authorized and not available from any other source (i.e., educational services). The federal Individuals with Disabilities Education Act (IDEA) requires public school systems to provide FM systems for educational purposes for students starting at age three (3). Arkansas Medicaid does not cover FM systems for children who are eligible for this service through IDEA.
A request for prior authorization may be submitted for medically necessary FM systems (procedure code V5273 for use with cochlear implant) that are not covered through IDEA; each request must be submitted with documentation of medical necessity. These requests will be reviewed on an individual basis.
The repair or replacement of the cochlear implant external speech processor and other supplies (including batteries, cords, battery charger and headsets) will be covered in accordance with the Arkansas Medicaid policy for the Physician and Prosthetics Programs. The covered services must be billed by an Arkansas Medicaid Physician or Prosthetics provider. The supplier is required to request prior authorization for repairs or replacements of external implant parts.
A request for prior authorization of a medically necessary FM system (V5273 for use with cochlear implant) and replacement cochlear implant parts requires a paper submission to DHS or its designated vendor. View or print contact information for how to submit the PA requestusing form DMS-679A. All documentation supporting medical necessity should be attached to the form. The provider will be notified in writing of the approval or denial of the request for prior authorization. View or print form DMS-679A and instructions for completion.
Prior authorization does not guarantee payment for services or the amount of payment for services. Eligibility for, and payment of, services are subject to all terms, conditions and limitations of the Arkansas Medicaid Program. Documentation must support medical necessity. The provider must retain all documentation supporting medical necessity in the beneficiary's medical record.
The following procedure codes must be prior authorized. Providers should use the following procedure codes when requesting prior authorization for replacement parts for cochlear implant devices. Applicable manufacturer warranty options must be exhausted before coverage is considered. Most warranties include one (1) replacement for a stolen, lost or damaged piece of equipment free-of-charge by the manufacturer.
The table below contains new and existing HCPCS procedure codes for FM systems for use with cochlear implant and replacement cochlear implant parts.
NOTE: Coverage and billing requirements for the physician provider for cochlear device implantation are unchanged.
Procedure Code | M1 | Age Restriction | PA | Payment Method |
L8627* | EP | 0-20 | Y | Manually Priced |
L8628* | EP | 0-20 | Y | Manually Priced |
L8629* | EP | 0-20 | Y | Manually Priced |
*Denotes paper claim
See Section 242.155 for information on billing and reimbursement for FM system and replacement cochlear implant parts.
Arkansas Medicaid covers the automatic electronic blood pressure monitor for beneficiaries of all ages as a rental-only item. A provider must substantiate that an accurate blood pressure reading cannot be obtained by using a regular blood pressure monitor. Providers must also supply one (1) disposable blood pressure cuff each month.
Prior authorization is required for the use of this item. Providers may request prior authorization by submitting form DMS-679A, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to DHS or its designated vendor. View or print form DMS-679A and instructions for completion. View or print contact information for how to submit the request.
The request for an enteral nutrition pump is covered on a case-by-case basis for beneficiaries under age twenty-one (21) who require supplemental feeding because of medical necessity. Sufficient medical documentation must be provided to establish that the enteral nutrition infusion pump is medically necessary (e.g., supplemental feeding must be given over an extended period of time due to reflux, cystic fibrosis, etc.). The PCP or appropriate physician specialist must prescribe the pump, citing the medical reason that bolus feeds are inappropriate.
Reimbursement for use in the home may be made for the pump supply kit when the feeding method involves an enteral nutrition infusion pump. The pump supply kit and the infusion pump require prior authorization from DHS or its designated vendor using form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. View or print contact information for how to submit the request. View or print form DMS-679A and instructions for completion.
The enteral feeding pump supply kit, necessary for the administration of the nutrients when the feeding method involves an enteral nutrition infusion pump, is reimbursed on a per-unit basis with one (1) day equaling one (1) unit of service. A maximum of one (1) unit per day is allowed. The pump supply kit includes pump sets, containers and syringes necessary for administration of the nutrients.
Reimbursement for the enteral nutrition infusion pump is based on a rent-to-purchase methodology. Each unit reimbursed by Medicaid will apply towards the purchase price established by Medicaid. Reimbursement will only be approved for new equipment. Used equipment will not be prior authorized. View or print form DMS-679A and instructions for completion.
Requests for prior authorization for enteral pump repairs must be submitted to DHS or its designated vendor. Form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be used to request prior authorization. View or print contact information for how to submit the request. View or print form DMS-679A and instructions for completion.
Insulin pumps and supplies are covered by Arkansas Medicaid for beneficiaries of all ages.
Prior authorization is required for the insulin pump. A prescription and proof of medical necessity are required. The patient must be educated on the use of the pump, but the education is not a covered service.
Insulin is covered through the prescription drug program.
The following criteria will be utilized in evaluating the need for the insulin pump:
Prior authorization requests for the insulin pump and supplies must be submitted on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, to DHS or its designated vendor. View or print form DMS-679A and instructions for completion. View or print contact information for how to submit the request.
Arkansas Medicaid covers specialized rehabilitative equipment for Medicaid-eligible beneficiaries of all ages.
Some items of specialized equipment require prior authorization from DHS or its designated vendor. View or print form DMS-679A and instructions for completion. View or print contact information for how to submit the request.
Arkansas Medicaid covers specialized wheelchairs and wheelchair seating systems for individuals age two (2) through adulthood.
Some items of specialized equipment require prior authorization from DHS or its designated vendor. View or print form DMS-679 and instructions for completion. View or print contact information for how to submit the request.
The following restrictions apply to the coverage of orthotic appliances.:
The appropriate forms (or the required information in a different format) must accompany the form DMS-679A. View or print DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components and instructions for completion.
The forms and their titles are as follows:
1. | DMS-647 | Gait Analysis: Full Body. View or print form DMS-647. |
2. | DMS-648 | Upper-Limb Prosthetic Evaluation. View or print form DMS-648. |
3. | DMS-649 | Upper-Limb Prosthetic Prescription. View or print form DMS-649. |
4. | DMS-650 | Lower-Limb Prosthetic Evaluation. View or print form DMS-650. |
5. | DMS-651 | Lower-Limb Prosthetic Prescription. View or print form DMS-651. |
A prescription for oxygen must be accompanied by a current arterial blood gas (ABG) laboratory report from a certified laboratory or the beneficiary's attending physician. A current laboratory report is defined as one performed within a maximum of thirty (30) days prior to the prescription for oxygen.
A prescription for oxygen must specify the oxygen flow rate, frequency and duration of use, estimate of the period of need for oxygen and method of delivery of oxygen to the beneficiary (e.g., two liters per minute, ten (10) minutes per hour, by nasal cannula for a period of two months). A prescription containing only "oxygen PRN" is not sufficient.
The following medical criteria will be utilized in evaluating coverage of oxygen:
Resting Pa02 less than 55 mm Hg
Resting Pa02 less than 60 mm Hg
Pa02 with exercise less than 55 mm Hg
Symptomatic at rest, with Pa02 less than 60 mm Hg
Resting Pa02 less than 60 mm Hg
Reviewed on an individual basis
O2 saturation below 94% by pulse oximeter with elevated PCO2 by capillary blood gas or end-tidal CO2 on two separate occasions.
The prior authorization request for all oxygen and respiratory equipment must be submitted on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to DHS or its designated vendor for beneficiaries of all ages. View or print form DMS-679A and instructions for completion. View or print contact information for how to submit the request.
The request for prior authorization must originate with the prosthetics provider. The provider is responsible for obtaining the required medical information and prescription needed for completion of the prior authorization request form. View or print contact information for how to submit the request.
Reimbursement for repairs to the enteral nutrition infusion pump requires prior authorization. Repairs will be approved only on equipment purchased by Medicaid. Therefore, no repairs will be reimbursable prior to the equipment becoming the property of the Medicaid beneficiary.
Requests for prior authorization for enteral pump repairs must be submitted to DHS or its designated vendor. View or print contact information for how to submit the request. Requests must be made on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. (View or print form DMS-679A and instructions for completion.)
The repair invoice and the serial number of the equipment must accompany the prior authorization request form. Total repair costs to an infusion pump may not exceed $290.93. Medicaid will not reimburse for additional repairs to an infusion pump after the provider has billed repair invoices totaling $290.93. If the equipment is still not in working order after the provider has billed the Medicaid maximum allowed for repairs, the provider must supply the beneficiary with a new infusion pump and may bill either procedure code B9000 or B9002 after receiving prior authorization for the new piece of equipment.
The gradient compression stocking (Jobst) is payable for beneficiaries of all ages. However, before supplying the item, the Jobst stocking must be prior authorized by DHS or its designated vendor. View or print contact information for how to submit the request. Documentation accompanying form DMS-679A must indicate that the beneficiary has severe varicose veins with edema, or a venous stasis ulcer, unresponsive to conventional therapy such as wrappings, over-the-counter stockings and Unna boots. The documentation must include clinical medical records from a physician detailing the failure of conventional therapy. View or print form DMS-679A and instructions for completion.
National Procedure Code | M1 | M2 | Description | Maximum Units |
A6530 | NU EP | Gradient compression stocking, below knee, 18-30mm Hg, each | Maximum 4 units per date of service | |
A6549 | NU | Gradient compression stocking, NOS (Jobst); 1 unit = 1 stocking | Maximum 4 units per date of service |
Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under twenty-one (21) years of age. When a second modifier is listed, that modifier must be used in conjunction with EP.
The procedure codes require prior authorization from DHS or its designated vendor. View or print contact information for how to submit the request.
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a "Y" in the column; if not, an "N" is shown.
***(.) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.
National Procedure Code | M1 | M2 | Description | Maximum Units | PA | Payment Method |
B4035 | EP | Enteral feeding supply kit, pump fed, per day (1 unit = 1 day) | 1 per day | Y | Purchase | |
B9000 | EP | Enteral nutrition infusion pump - without alarm (1 day = 1 unit) | 1 per day | Y | Rent to Purchase | |
B9002 | EP | Enteral nutrition infusion pump - with alarm (1 day = 1 unit) | 1 per day | Y | Rent to Purchase | |
K0739 | EP | U2 | ***(Repair or non-routine service for enteral nutrition infusion pump, requiring the skill of a technician, parts and labor) | Y |
Enteral Nutrition Infusion Pump
Reimbursement for the enteral nutrition infusion pump is based on a rent-to-purchase methodology. Each unit reimbursed by Medicaid will apply towards the purchase price established by Medicaid.
Reimbursement will only be approved for new equipment. Used equipment will not be prior authorized. Procedure codes B9000 and B9002 represent a new piece of equipment being reimbursed by Medicaid on the rent-to-purchase plan.
Codes B9000 and B9002 are reimbursed on a per unit basis with 1 day equaling 1 unit of service per day.
Medicaid will reimburse on the rent-to-purchase plan for a total of 304 units of service. After reimbursement has been made for 304 units, the equipment will become the property of the Medicaid beneficiary.
Prior authorization is required for codes B9000 and B9002. The prior authorization request must include the serial number of the infusion pump being provided to the beneficiary.
See Section 236.000 for reimbursement when the Medicaid Program is billed for repairs made to the enteral infusion pump.
Miscellaneous
A DME request is considered outdated by Medicaid when it is first presented to Medicaid more than ninety (90) days from the date it was written, signed and dated by the physician.
The Medicaid Utilization Management Program (MUMP) determines covered inpatient lengths of stay in general and rehabilitative hospitals, in state and out-of-state. The MUMP does not apply to lengths of stay in psychiatric facilities.
Length-of-stay determinations are made by the Quality Improvement Organization (QIO), under contract to the Arkansas Medicaid Program.
Reconsideration reviews of denied extensions may be expedited by submitting the medical record to DHS or its designated vendor. View or print contact information for how to submit the request.
A benefit extension approval or denial-or request for additional information-will be returned to the provider within thirty (30) calendar days.
DHS or its designated vendor performs retrospective reviews of medical records to determine the medical necessity of services paid for by Medicaid. View or print contact information for retrospective reviews.
Specific guidelines have been developed for retrospective review of occupational, physical and speech-language therapy services furnished to Medicaid beneficiaries under the age of twenty-one (21). Those guidelines are included in this manual to assist providers in determining and documenting medical necessity. The guidelines are found in Sections 216.100 through 216.108.
View or print contact information to obtain the DHS or designated vendor step-by-step process for an extended therapy services review.
The Medicaid Utilization Management Program (MUMP) is designed to manage the appropriateness and duration of RSPD services. The MUMP procedures apply to all RSPD providers.
Length-of-stay determinations are performed by the Quality Improvement Organization (QIO), under contract to the Arkansas Medicaid Program.
Medicaid beneficiaries are allowed up to four (4) days of RSPD services when the admission criteria (refer to Sections 213.000 through 213.300) are met. If a patient is not discharged before or during the fifth day of the residential stay, DHS or its designated vendor must certify any additional days.
When a patient is transferred from one RSPD facility to another, the stay must be certified by DHS or its designated vendor from the first day of transfer. (See Transfer Admissions, Section 217.132.) View or print contact information to obtain the DHS or designated vendor step-by-step process for submitting the request.
View or print contact information to obtain the DHS or its designated vendor step-by-step process for submitting the request.
If a patient is transferred from one RSPD facility to another, the receiving facility must contact DHS or its designated vendor within twenty-four (24) hours to certify the residential stay. View or print the contact information to obtain the DHS or designated vendor step-by-step process for submitting the request.
If a provider has not requested MUMP certification of an extension of days because there is apparent coverage by private insurance or Medicare Part A, but the other payer has denied the claim for non-covered service, lost eligibility, benefits exhausted, etc., post-certification of days beyond the first four (4) days may be obtained.) View or print contact information to obtain the DHS or designated vendor step-by-step process for submitting the request
Medicaid does not supply providers with Uniform Billing claim forms. Numerous venders sell CMS-1450 (UB-04 forms.) View a sample CMS-1450 (UB-04) claim form.
Complete Arkansas Medicaid program claims in accordance with the National Uniform Billing Committee UB-04 data element specifications and Arkansas Medicaid's billing instructions, requirements, and regulations for claim form CMS-1450.
The National Uniform Billing Committee (NUBC) is a voluntary committee whose work is coordinated by the American Hospital Association (AHA) and is the official source of information regarding CMS-1450 (UB-04.) View or print NUBC contact information.
The committee develops, maintains, and distributes to its subscribers the UB-04 Data Element Specifications Manual and periodic updates. The NUBC is also a vendor of CMS-1450 (UB-04) claim forms.
Following are Arkansas Medicaid's instructions for completing, in conjunction with the UB-04 Data Element Specifications Manual (UB-04 Manual), a CMS-1450 (UB-04) claim form.
Forward the original of the completed form to the Fiscal Agent's Claims Department. View or print DHS or its designated Fiscal Agent's contact information. One (1) copy of the claim form should be retained for your records.
NOTE: A provider furnishing services without verifying beneficiary eligibility for each date of service does so at the risk of not being reimbursed for the services. The provider is strongly encouraged to print the eligibility verification and retain it until payment is received.
DHS or its designated vendor must approve all requests for prior authorization for targeted case management services for Medicaid eligible beneficiaries under age twenty-one (21). View or print contact information to obtain instructions for submitting the request.
The following information must be submitted for Child Health Services (EPSDT) beneficiaries and for DDS eligible beneficiaries under the age of twenty-one (21):
NOTE: A family group should be managed by only one case manager for any targeted case management service.
Requests for prior authorization must be submitted using the Request for Targeted Case Management Prior Authorization for Beneficiaries Under Age 21 Form (DMS-601). View or print form DMS-601. The documentation submitted with the prior authorization request must support the medical necessity of the requested services.
A medical necessity determination will be made within fifteen (15) working days of receipt of a completed prior authorization request. For prior authorization requests meeting the medical necessity requirements, an authorization number designation, the length of services, procedure codes and units approved for the requesting provider will be issued. For denied requests, a letter containing case-specific rationale that explains why the request was not approved will be sent to the requesting provider and to the Medicaid beneficiary.
EIDT and ADDT transportation providers are required to prepare and submit an annual EIDT/ADDT Survey (View or print EIDT/ADDT Transportation Survey DMS-632)and other applicable information concerning the survey to the Arkansas Department of Human Services Division of Medical Services, Provider Reimbursement Unit. View or print the Arkansas Department of Human Services Division of Medical Services, Provider Reimbursement Unit contact information.
The survey information will be reported for the provider's fiscal period. The survey must be submitted within five (5) months after the close of the provider's fiscal year end. Providers with financial reporting periods of less than six (6) months are not required to submit a survey. However, if no survey is required, the provider must notify the Division of Medical Services (DMS) in writing why the survey is not being submitted. Failure to submit the completed survey or failure to submit a written explanation of a reporting period of less than six (6) months within the prescribed period, except as expressly extended by the State Medicaid agency, may result in the suspension of reimbursement until DMS receives this information.
Survey information requested includes direct and indirect/overhead costs, revenues and client mileage information associated with and applicable to the EIDT or ADDT Transportation Program. No other program costs, revenues or mileage information is to be included on the survey. If the provider provides transportation services for programs other than EIDT or ADDT programs, please remove the other program costs, revenues and mileage information before completing the survey and submit a narrative describing how these other transportation program amounts were calculated and removed. All cost and revenue amounts are to be reported using the accrual method of accounting and will be reported in whole dollar amounts, no cents.
Providers must also submit with the survey a written general description of what costs are included with indirect/overhead costs and how these costs were identified, calculated and allocated to the EIDT or ADDT transportation program.
Providers are required to maintain adequate financial records, mileage data and rider data for proper documentation and support of the cost and statistical information reported on the annual survey. These records must be retained for a period of five (5) years after submission of the survey. The surveys, supporting documentation and provider narratives are subject to on-site review and inspection by DHS/DMS personnel.
EIDT and ADDT providers may order copies of Form DMS-632 on the Medicaid Form Request. Requests may be forwarded to the DHS or designated Fiscal Agent's Provider Assistance Center. View or print the DHS or designated Fiscal Agent's contact information.
Reimbursement for ventilator equipment must have prior approval by DHS or its designated vendor. View or print contact information to obtain instructions for submitting the request.
A request for prior authorization must originate with the provider of ventilator equipment. The provider is responsible for obtaining the required medical information and necessary prescription information needed for completion of form DMS-679. This form must be signed and dated by the physician. View or print form DMS-679 and instructions for completion.
Providers must specify the brand name/model of the ventilator on the prior authorization request.
The documentation submitted with the prior authorization request must support the medical necessity of the requested ventilator. If necessary additional information (i.e., original prescription, records from the hospitalization initiating the need for ventilator, etc.) shall be requested from the provider.
A prior authorization of ventilator equipment services does not guarantee payment.
Providers must note the date the ventilator is no longer in daily use.
When a prior authorization (PA) request is approved, a prior authorization control number will be assigned and returned to the requesting provider.
Prior authorization approvals are authorized for a maximum of six (6) months (180 days) or for the life of the prescription, whichever is shorter. A new request must be made for services needed for a longer period of time.
The effective date of the pa will be the date the beneficiary begins using the equipment or the day following the last day of the previous prior authorization approval.
Within thirty (30) working days before the end of an authorization for ventilator equipment, the provider must obtain a new prescription and submit a new Medical Equipment Request for Prior Authorization and Prescription (form DMS-679) signed by the prescribing physician.
PA for ventilator equipment does not guarantee payment. The beneficiary must be Medicaid-eligible on the dates of service and must have available benefits. The provider must follow all applicable billing procedures.
Submit a copy of the Medical Assistance Remittance and Status Report reflecting the claim's denial for exhausted benefits with the request. Do not send a claim.
Requests for extension of benefits for Clinical Services (Physician's Visits) Outpatient Services (Hospital Outpatient visits), Laboratory Services (Lab Tests) and X-ray services (X-ray, Ultrasound, Electronic Monitoring-EEG, EKG, etc.) must be submitted to DHS or its designated vendor for consideration. View or print contact information to obtain instructions for submitting the request. Requests for extension of benefits requires correct completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray (form DMS-671). View or print DMS-671 form.
Instructions for accurate competition of form DMS-671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each provider manual.
PRESCRIPTION DRUG INFORMATION
Act 186 of 1997 authorizes optometrists to prescribe and administer both oral and topical drugs for the diagnosis and treatment only of conditions of the eye, lids, adnexa or visual system, except for those drugs listed in Schedules I and II of the Uniform Controlled Substance Act. They can also prescribe and administer epinephrine, Benadryl® or other comparable medication for the emergency treatment of anaphylaxis or anaphylactic reactions.
Medicaid covers prescription drugs in accordance with policies and regulations set forth in this section and pursuant to orders (prescriptions) from authorized prescribers. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. A numeric listing of approved pharmaceutical companies and their respective vendors is located on the DHS or designated Pharmacy vendor website. View or print numeric listing of approved pharmaceutical companies and their respective labeler codes. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with listed labeler codes.
For prescription drug prior authorization concerns or the latest information regarding prescription drug coverage, providers may visit the Prescription Drug PA Help Desk.
For questions regarding the Evidence-Based Prescription Drug Program or to request an override for non-preferred drugs, prescribers may contact the DHS Contracted Pharmacy Vendor Help Desk.
Extension of Benefits must be submitted to DHS or its designated vendor for review. View or print contact information to obtain a step-by-step outline for the extension process.
The CMS-1500 claim form must be used by the ophthalmologists or optometrists when billing the Medicaid Program for non-prescription services. Submit the completed claim form to the Arkansas Medicaid fiscal agent.
If prescription services are required and are within the allowable limits outlined in Section 213.200, the provider must complete the prescription form provided by the optical contractor. Visual Care providers who submit claims electronically must submit a copy of the eligibility verification for the date on which the service is being provided along with the prescription form to the optical contractor for processing. The printout will provide verification of the beneficiary's eligibility, last visual exam date and last optical prescription date. (A photocopy of the beneficiary's plastic identification card will not be accepted by the optical contractor.) The prescription form and the eligibility verification can be sent to the optical contractor. View or print the DHS Designated Optical Contractor contact information.
If the copy of the eligibility on the date of service is not verified, and/or the benefit has been exhausted, the optical contractor will not fill the prescription and will return the claim to the physician.
All provider manuals, manual updates, notices of rule making, official notices and RAs are available for downloading, without charge, from the Arkansas Medicaid website.
Enrolled providers may purchase extra paper copies of a manual through the fiscal agent. See information below regarding purchasing copies. Persons, entities and organizations that are not enrolled providers may purchase a paper copy of a provider manual through the fiscal agent.
The cost for a printed copy of an Arkansas Medicaid provider manual is $125.00.
Send orders for printed manuals to the Arkansas Medicaid Fiscal Agent, Information Library Unit. Include with your order a check made to the Fiscal Agent for the appropriate amount. View or print the manual order contact information.
Provider assistance and education and the processing of claims for the Medicaid program are performed by an independent contractor.
The Arkansas Medicaid Fiscal Agent has a staff of claims representatives available to assist with any needs concerning claims.
The Arkansas Medicaid Fiscal Agent maintains a Provider Assistance Center (PAC) to assist Arkansas Medicaid providers.
The Arkansas Medicaid fiscal agent has a full-time staff of Provider Representatives available for consultation regarding billing problems and technical assistance that cannot be resolved through the Provider Assistance Center. Provider Representatives are available to visit providers' offices to provide training on billing and on-site technical assistance. To find your Provider Representative to schedule a visit, view the DHS or designated vendor's Outreach Specialistspage.
Providers can review instructions for Prior Authorization Requests in the Section II of their program's provider manual.
Some prior authorizations are processed by other Medicaid contractors:
The Claim Adjustments report has two parts. The first includes the adjustment transaction header elements. In this section, the Arkansas Medicaid fiscal agent identifies the adjustment transaction with an internal control number (ICN). Adjustment ICNs are formatted in the same way as claim numbers; the first two digits of an adjusted claim ICN indicate the type of adjustment:
50 | Adjustments - Non-Check Related |
51 | Adjustments - Check Related |
52 | Mass Adjustments - Non-Check Related |
53 | Mass Adjustments - Check Related |
54 | Mass Adjustments - Void Transaction |
55 | Mass Adjustments - Provider Retro Rates |
56 | Adjustments - Void Non-Check Related |
57 | Adjustments - Void Check Related |
58 | Adjustment - Processed by Fiscal Agent's System Engineer |
59 | Adjustments/Voids Web - 837 |
60 | Adjustments by State - Non-Check Related |
61 | Adjustments by State - Check Related |
63 | Adjustments Non Check History Only Adjustment |
64 | Void by State - Non-Check Related |
65 | Void by State - Check Related |
66 | History Only Non-Check Related Adjustment |
67 | History Only Check Related Adjustment |
68 | Adjustments Check Related History Only Adjustment |
72 | Encounter Adjustments |
73 | Encounter Mass Adjustments |
74 | Adjustments - Encounter |
75 | Adjustments - Encounter Void |
Displayed to the right of the ICN are the provider's patient control number or medical record number from the original claim, the claim beginning and ending dates of service and the original billed amount. Keep in mind that the Arkansas Medicaid fiscal agent adjusts the entire claim, even if only one detail paid in error, so the total billed amount shown here is the total billed amount of the entire claim being adjusted. Other withheld or credited amounts that impact the paid amount are listed and can include insurance, spenddown, copay (coinsurance) and deductible amounts. The Adjustment EOB code entered when the claim was adjusted indicates the reason for initiating the claim adjustment.
The second part of the adjustment transaction displays the claim details and the adjudication of the reprocessed claim. Detail EOBs for each procedure code are shown.
Additional payment, overpayment to be withheld, refund amount applied as well as total claim adjustments are shown at the bottom of the Claim Adjustments report. The actual withholding of the original paid amount does not occur in the Claim Adjustments report; it occurs in the Financial Transactions report of the RA. Adjustments are listed in the Accounts Receivable section, with the appropriate amounts displayed under the field headings "A / R (Action/Reason) Number," "Setup Date,": "Original Amount," "Recoupment Amount to Date," "Balance," "Reason Code," "Adjustment ICN," "Previous ICN," and "Amount Recouped in Current Cycle." (See the discussion of Financial Transactions in Section 314.170.)
Finally, the total of all adjusted amounts paid or withheld from the remittance are displayed in the Summary report of the RA under the field header Claims Data "Claim Adjustments" and Earnings Data "Payments: Claim Specific: Current Cycle."
If medical services are provided to a patient who is entitled to and is enrolled with coverage within the original Medicare plan under the Social Security Act and also to Medicaid benefits, it is necessary to file a claim only with the original Medicare plan. The claim must be filed according to Medicare's instructions and sent to the Medicare intermediary. The claim should automatically cross to Medicaid if the provider is properly enrolled with Arkansas Medicaid and indicates the beneficiary's dual eligibility on the Medicare claim form. According to the terms of the Medicaid provider contract, a provider must "accept Medicare assignment under Title XVIII (Medicare) in order to receive payment under Title XIX (Medicaid) for any appropriate deductible or coinsurance which may be due and payable under Title XIX (Medicaid)." See Section 142.700 for further information regarding Medicare/Medicaid mandatory acceptance of assignment for providers.
When the original Medicare plan intermediary completes the processing of the claim, the payment information is automatically crossed to Medicare's Coordination of Benefits Agreement (COBA) process and from there crossed to Arkansas Medicaid and the claim is processed in the next weekend cycle for Medicaid payment of applicable coinsurance and deductible. The transaction will usually appear on the provider's Medicaid RA within four (4) to six (6) weeks of payment by Medicare. If it does not appear within that time, payment should be requested according to the instructions below.
Claims for Medicare beneficiaries entitled under the Railroad Retirement Act do not cross to Medicaid. The provider of services must request payment of co-insurance and deductible amounts through Medicaid according to the instructions below, after Railroad Retirement Act Medicare pays the claim.
Medicare Advantage/Medigap Plans (like HMOs and PPOs) are health plan options that are available to beneficiaries, approved by Medicare, but run by private companies. These companies bill Medicare and pay directly through the private company for benefits that are a part of the Medicare Program, as well as offering enhanced coverage provisions to enrollees. Since these claims are paid through private companies and not through the original Medicare plan directly, these claims do not automatically cross to Medicaid; and the provider must request payment of Medicare covered services co-insurance and deductible amounts through Medicaid according to the below instructions after the Medicare Advantage/Medigap plan pays the claim.
When a provider learns of a patient's Medicaid eligibility only after filing a claim to Medicare, the instructions below should be followed after Medicare pays the claim.
Instructions: The Arkansas Medicaid fiscal agent provides software and web-based technology with which to electronically bill Medicaid for crossover claims that do not cross to Medicaid.
Additional information regarding electronic billing can be located in this Sections 301.000 through 301.200. Providers are strongly encouraged to submit claims electronically or through the Arkansas Medicaid website. Front-end processing of electronically and web-based submitted claims ensures prompt adjudication and facilitates reimbursement.
Providers without electronic billing capability must mail the appropriate National Standard Claim Form (CMS-1500 or CMS-1450) to the Fiscal Agent. Along with the National Standard Claim Form, providers must submit attachment DMS-600. (View or print attachment DMS-600.) Providers must also submit the Medicare Explanation of Benefits (EOMB). Claims must be submitted in the following order:
Paper claims will be returned to the provider if not submitted in the above order.
State Agency
Supplement 1 to Attachment 3.1-A
Page 5
Revised: August 1, 2021
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
State/Territory: ARKANSAS
TARGETED CASE MANAGEMENT SERVICES
[Target Group]
Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers, according to established program guidelines.
Monitoring visits may be as frequent as necessary, within established Medicaid maximum allowable limitations.
Monitoring is allowed through regular contacts with service providers at least every other month to verify that appropriate services are provided in a manner that is in accordance with the service plan and assuring through contacts with the beneficiary, at least every other month, that the beneficiary continues to participate in the service plan and is satisfied with services.
Face to face monitoring contacts must be completed as often as deemed necessary, based on the professional judgment of the TCM, but no less frequent than established in Medicaid TCM program policy.
Case management includes contacts with non-eligible individuals that are directly related to identifying the eligible individual's needs and care, for the purposes of helping the eligible individual access services; identifying needs and supports to assist the eligible individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the eligible individual's needs.
(42 CFR 440.169(e))
Qualifications of providers (42 CFR 441.18(a)(8)(v) and 42 CFR 441.18(b)):
Case management providers must be certified by the Division of Provider Services and Quality Assurance on a annual basis, unless approved otherwise by the Division of Medical Services, based on performance evaluation or other approved data.
016.06.21 Ark. Code R. 006