Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.07-022 - Section V Provider Manual Update Transmittal

Current through Register Vol. 49, No. 6, June, 2024
The following is a listing of the red-ink claim forms required
				by Arkansas Medicaid. The forms below cannot be printed from this manual for
				use. Information on where to get the forms and links to samples of the forms
				are available below. To view a sample of the form click the form name.
Claim Type
Where To Get Them
Professional ? CMS-1500
Business Form Supplier
Institutional ? CMS-1450
Business Form Supplier
EPSDT ?
						  DMS-694
**
EDS - 1-800-457 -4454
Visual Care ? DMS-26-V
EDS - 1-800-457 -4454
Inpatient Crossover ? EDS-MC-001
EDS - 1-800-457 -4454
Long Term Care Crossover ?
						  EDS-MC-002
EDS - 1-800-457 -4454
Outpatient Crossover ? EDS-MC-003
EDS - 1-800-457 -4454
Professional Crossover ? EDS-MC-004
EDS - 1-800-457 -4454
** A printable
PROVIDER INTEROFFICE DOCUMENTATION ONLY
version of this form is available below under Arkansas Medicaid
				Forms.
Claim Forms
The following is a listing of the non-red-ink claim forms
				required by Arkansas Medicaid. Information on where to get a supply of the
				forms and links to samples of the forms are available below. To view a sample
				of the form click the form name.
Claim Type
Where To Get Them
Alternatives Attendant Care Provider
						  Claim Form -AAS-9559
Client Employer
Dental ? ADA-J400
Business Form Supplier
Hospice/INH Claim Form ? DHS-754
EDS ? 1-800-457 -4454
Arkansas Medicaid Forms
The forms below can be printed from this manual for use.
In order by form name:
Form Name
Form Number
Acknowledgement of Hysterectomy Information
DMS-2606
Address Change Form
DMS-673
Adjustment Request Form - Medicaid XIX
EDS-AR-004
AFMC Personal Care Assessment and Service Plan for
						  Medicaid Beneficiaries Under Age 21
AFMC-201
AFMC Prescription & Prior Authorization Request for
						  Medical Equipment Excluding Wheelchairs & Wheelchair Components
AFMC-103
AFMC Request For Bilaminate Skin Substitutes
AFMC-RBSS
Amplification/Assistive Technology Recommendation
						  Form
DMS-686
Approval/Denial Codes for Inpatient Psychiatric
						  Services
DMS-2687
Arkansas Early Intervention Infant & Toddler
						  Program Intake/Referral/Application for Services
DDS/FS#0001.a
ARKids First Mental Health Services Provider
						  Qualification Form
DMS-612
Assisted Living Waiver Plan of Care
AAS-9565
Authorization for Automatic Deposit
autodeposit
Authorization for Payment for Services Provided
MAP-8
Certification of Need - Medicaid Inpatient Psychiatric
						  Services for Under Age 21
DMS-2633
Certification of Schools to Provide Comprehensive EPSDT
						  Services
CSPC-EPSDT
Certification Statement for Abortion
DMS-2698
CHMS Benefit Extension for Diagnosis/Evaluation
						  Procedures
AFMC-102
CHMS Request for Prior Authorization
AFMC-101
Claim Correction Request
DMS-2647
Consent for Release of Information
DMS-619
Contract to Participate in the Arkansas Medical
						  Assistance Program
DMS-653
DDTCS Transportation Log
DMS-638
DDTCS Transportation Survey
DMS-632
Dental Treatment Additional Information
DMS-32-A
Disproportionate Share Questionnaire
DMS-628
Early and Periodic Screening, Diagnosis and Treatment
						  (EPSDT) Prescription/Referral For Medically Necessary Services/Items Not
						  Specifically Included in the Medicaid State Plan
DMS-693
Early Childhood Special Education Referral Form
ECSE-R
EPSDT Claim Form ? You may print this version for use
						  in charts and electronic billing documentation; however, if you submit a paper
						  claim for billing, you must use the red-ink version (see Red-ink Claim Forms
						  above.)
EPSDT-DMS-694
EPSDT Provider Agreement
DMS-831
Evaluation Form Lower-Limb
DMS-646
Explanation of Check Refund
EDS-CR-002
Gait Analysis Full Body
DMS-647
Home Health Certification and Plan of Care
CMS-485
Hospital/Physician/Certified Nurse Midwife Referral for
						  Newborn Infant Medicaid Coverage
DCO-645
Individual Renewal Form for DDTCS Therapists &
						  School Based Therapists
DMS-0663
Inpatient Psychiatric Medicaid Agency Review Team
						  Transmittal Sheet
DMS-2685
Lower-Limb Prosthetic Prescription
DMS-651
Media Selection/E-Mail Address Change Form
None
Medicaid Claim Inquiry Form
EDS-CI-003
Medicaid Form Request
EDS-MFR-001
Medical Assistance Dental Disposition
DMS-2635
Medical Equipment Request for Prior Authorization &
						  Prescription
DMS-679
Medical Transportation and Personal Assistant
						  Verification
DMS-616
Mental Health Services Provider Qualification Form for
						  LCSW, LMFT and LPC
DMS-633
Notice Of Noncompliance
DMS-635
NPI Reporting Form
DMS-683
Occupational, Physical and Speech Therapy for Medicaid
						  Eligible Beneficiaries Under Age 21 Prescription/Referral
DMS-640
Personal Care Assessment and Service Plan
DMS-618
Prescription & Prior Authorization Request For
						  Nutrition Therapy & Supplies
DMS-2615
Prescription Drug Prior Authorization and Extension of
						  Benefits Request Form
DMS-2694
Primary Care Physician Managed Care Program Referral
						  Form
DMS-2610
Primary Care Physician Participation Agreement
DMS-2608
Primary Care Physician Selection and Change Form
DMS-2609
Prosthetic-Orthotic Lower-Limb Amputee
						  Evaluation
DMS-650
Prosthetic-Orthotic Upper-Limb Amputee
						  Evaluation
DMS-648
Provider Application
DMS-652
Provider Communication Form
AAS-9502
Provider Enrollment Application and Contract
						  Package
AppMaterial
Referral for Certification of Need Medicaid Inpatient
						  Psychiatric Services for Under Age 21
DMS-2634
Referral for Medical Assistance
DMS-630
Request for Extension of Benefits
DMS-699
Request for Extension of Benefits for Clinical,
						  Outpatient, Laboratory and X-Ray Services
DMS-671
Request for Extension of Benefits for Medical Supplies
						  for Medicaid Beneficiaries Under Age 21
DMS-602
Request For Orthodontic Treatment
DMS-32-0
Request for Private Duty Nursing Services Prior
						  Authorization and Prescription - Initial Request or Recertification
DMS-2692
Request for Targeted Case Management Prior
						  Authorization for Beneficiaries Under Age 21
DMS-601
Sterilization Consent Form
DMS-615 English DMS-615
						  Spanish
Sterilization Consent Form - Information for Men
PUB-020
Sterilization Consent Form - Information for
						  Women
PUB-019
Upper-Limb Prosthetic Prescription
DMS-649
Vendor Performance Report
None
Verification of Medical Services
DMS-2618
In order by form number:
AAS-9502
DMS-2685
DMS-650
AAS-9565
DMS-2687
DMS-651
Address Change
DMS-2692
DMS-652
AFMC-101
DMS-2694
DMS-653
AFMC-102
DMS-2698
DMS-671
AFMC-103
DMS-32-A
DMS-673
AFMC-201
DMS-32-O
DMS-679
AFMC-RBSS
DMS-601
DMS-683
Authorization for
DMS-602
DMS-686
Automatic Deposit
DMS-612
DMS-693
CMS-485
DMS-615
DMS-694 chart version
CSPC-EPSDT
DMS-616
DMS-694 sample
DCO-645
DMS-618
DMS-699
DDS/FS#0001.a
DMS-619
DMS-831
DMS-0663
DMS-628
ECSE-R
DMS-2606
DMS-630
EDS-AR-004
DMS-2608
DMS-632
EDS-CI-003
DMS-2609
DMS-633
EDS-CR-002
DMS-2610
DMS-635
EDS-MFR-001
DMS-2615
DMS-638
MAP-8
DMS-2618
DMS-640
Performance Report
DMS-2633
DMS-646
Provider Enrollment
DMS-2634
Application and Contract
DMS-2635
DMS-647
						  DMS-648
Package
DMS-2647
DMS-649
PUB-019
PUB-020
Arkansas Medicaid Contacts and Links
Click the link to view the information.
American Hospital
				Association
Americans with Disabilities Act
				Coordinator
APS Healthcare Midwest
				(APS)
Arkansas Department of Education, Health and
				Nursing Services Specialist
Arkansas Department of Education, Special
				Education
Arkansas DHHS Division of Human Services -
				Aging and Adult Services
Arkansas DHHS Division of Human Services ?
				Appeals and Hearings Section
Arkansas DHHS Division of Human Services,
				Child Care and Early Childhood Education, Child Care Licensing
				Unit
Arkansas DHHS Division of Human Services,
				Children and Family Services, Contracts Management
				Unit
Arkansas DHHS Division of Human Services,
				Children's Services
Arkansas DHHS Division of Human Services,
				County Operations - Customer Assistance Section
Arkansas DHHS Division of Human Services,
				Medical Services
Arkansas DHHS Division of Human Services,
				Medical Services Dental Care Unit
Arkansas DHHS Division of Human Services,
				Medical Services Director
Arkansas DHHS Division of Human Services,
				Medical Services Financial Activities Unit
Arkansas DHHS Division of Human Services,
				Medical Services Hearing Aid Consultant
Arkansas DHHS Division of Human Services,
				Medical Services Medical Assistance Unit
Arkansas DHHS Division of Human Services,
				Medical Services Pharmacy Unit-Utilization Review
				Section
Arkansas DHHS Division of Human Services,
				Medical Services Third-Party Liability Unit
Arkansas DHHS Division of Human Services,
				Medical Services UR Benefit Extension Requests
				Section
Arkansas DHHS Division of Human Services,
				Medical Services UR/Home Health Extensions
Arkansas DHHS Division of Human Services,
				Medical Services Utilization Review Section
Arkansas DHHS Division of Human Services,
				Medical Services Visual Care Coordinator
Arkansas DHHS Division of Human Services,
				Medical Services, Provider Reimbursement Unit
Arkansas DHHS, Division of
				Health
Arkansas DHHS, Division of Health, Health
				Facility Services
Arkansas DHHS, Division of Human Services,
				Accounts Receivable
Arkansas Foundation For Medical
				Care
Arkansas Hospital Association Contact
				Information
Arkansas Medicaid Provider Enrollment
				Unit
ARKids First-B ID Card
				Example
ARKids First-B Telephone
				Number
Central Child Health Services
				Office
ConnectCare
				Helpline
County Codes
CPT Ordering
				Information
EDS Claims
				Department
EDS EDI Support Center (formerly AEVCS Help
				Desk)
EDS Inquiry Unit
EDS Manual Order
				Address
EDS Pharmacy Help
				Desk
EDS Provider Assistance Center
				(PAC)
EDS Supplied Forms
Example of Beneficiary Notification of Denied
				ARKids First-B Claim
Example of Beneficiary Notification of Denied
				Medicaid Claim
First Connections Infant & Toddler
				Program Developmental Disabilities Services
First Health
Flow Chart of Intake and Prior Authorization
				Process For Intervention/Treatment
Health Care
				Declarations
ICD-9-CM Ordering
				Information
Immunizations Registry Help Desk ? DHHS
				Division of Health
Medicaid ID Card
				Example
Medicaid Reimbursement Unit Communications
				Hotline
Medicaid Tooth Numbering
				System
National Supplier
				Clearinghouse
Primary Care Physician (PCP) Enrollment Voice
				Response System
Provider Qualifications Division of Mental
				Health Services
Select Optical
Standard Register
Table of Desirable
				Weights
U.S. Government Printing
				Office
Vendor Performance
				Report
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Instructions for Completion of Request for
				Extension of Benefits ? DMS-699 (Rev.4/07)
All Required Fields of Form DMS-699 Must be
				Correctly Completed by Entering
The Following
				Information
Enter Provider Name, Address, City, State, Zip Code ?
REQUIRED
Enter Patient?s Full Name ?
REQUIRED
Enter Patient?s Address, City, State, Zip Code ? If
				Available
Enter Patient?s Arkansas Medicaid ID Number, Birth Date, and
				Sex ?
REQUIRED
Enter Diagnoses -Primary to Request First- Then Additional if
				Applicable ?
REQUIRED
Enter Correct Medicaid Procedure Code for Items Requested for
				Extension ?
REQUIRED
Enter Correct ?Type of Service Code? or
All Applicable
				Modifiers (After 07/01/07)
?
REQUIRED
Enter From Date of Service ?
REQUIRED
Enter To Date of Service ?
REQUIRED
Enter Correct Number of Units Being Requested ?
REQUIRED
Enter Provider ID Number ?
REQUIRED
Enter Provider Taxonomy Code - if Applicable
Complete with an Original Signature by Provider or Provider?s
				Authorized Representative -
REQUIRED
ATTACH A SUMMARY AND MEDICAL RECORDS AS NEEDED TO JUSTIFY
				MEDICAL NECESSITY ?
REQUIRED
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Instructions for Completion of the EPSDT Claim Form ?
				DMS-694
EDS offers providers several options for electronic billing.
				Therefore, claims submitted on paper are paid once a month. The only claims
				exempt from this process are those which require attachments or manual
				pricing.
To bill for a Child Health Services (EPSDT) screening service,
				use the claim form DMS-694. The numbered items correspond to numbered fields on
				the claim form. The DMS-694 is used as a combined referral, screening results
				document and a billing form. Each screening should be billed separately,
				providing the appropriate information for each of the screening components. The
				following numbered items correspond to numbered fields on the claim
				form.
Medical services such as immunizations and laboratory
				procedures may also be billed on the DMS-694 when provided in conjunction with
				a Child Health Services (EPSDT) screening, as well as other treatment services
				provided.
The following instructions must be read and carefully adhered
				to, so that EDS can efficiently process claims. 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.
Completed claim forms should be forwarded to the EDS Claims
				Department.
View or print the EDS Claims Department contact
				information.
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.
Field Name and Number
Instructions for Completion
1. Patient?s Last Name
Enter the patient?s last name.
2. Patient?s First Name
Enter patient?s first name.
3. Patient?s Middle Initial
Enter patient?s middle initial.
4. Patient?s Sex
Check ?M? for male or ?F? for female.
5. Patient?s Medicaid ID No.
Enter the entire 10-digit patient Medicaid
						  identification number.
6. Casehead?s Name
Enter the casehead name for TEA children only.
						  Patient?s name has been requested in Blocks 1, 2 and 3.
7. County of Residence
Enter the patient?s county of residence.
8. Date of Birth
Enter the patient?s date of birth in month and year
						  format as it appears on the Medicaid identification card.
9. Street Address
Enter the patient?s street address.
10. City
Enter the patient?s city of residence.
11. If a Patient is a Referral Enter Name of Referring
						  Physician
Provider Identification Number/Taxonomy Code
If the patient is a referral, enter the name of the
						  referring physician and his or her provider identification number and taxonomy
						  code.
12. Medical Record Number
This is an optional entry that the provider may use for
						  accounting purposes. Enter the patient?s account number, if applicable. Up to
						  16 numeric or alpha characters will be accepted. This number will appear on the
						  Remittance Advice (RA) and is a method of identifying payment of the
						  claim.
13. Provider Phone Number
Pay To: Provider Name and Address
Pay To: Provider Number
Enter the provider?s complete name, address, provider
						  identification number, and taxonomy code. If a clinic billing is involved, use
						  the clinic provider identification number. Telephone number is requested but
						  not required.
14. Other Health Insurance
Coverage (Enter Name of Plan and Policy Number)
If applicable, enter the name of the insurance plan and
						  the policy number of any health insurance coverage carried by the patient other
						  than Medicaid. The patient?s Medicaid identification card should indicate ?Yes?
						  if other coverage is carried by the beneficiary.
15. Was Condition Related to:
A. Patient?s Employment
Check ?Yes? if the patient?s condition was employment
						  related. If the condition was not employment related, check ?No.?
B. An Accident
Check ?Yes? if the patient?s condition was related to
						  an accident. Check ?No? if the condition was not accident related.
16. Primary Diagnosis or Nature of Injury
Enter the description of the primary reason for
						  treatment of the patient.
Diagnosis Code
Enter the ICD-9-CM Code that identifies the primary
						  diagnosis.
18. Type of Screen Periodic Interperiodic
Not required for Medicaid. Completed by Human Services,
						  if applicable.
SECTION II
20. Examination Report
To be completed by screening provider at time of
						  screen.
A. Basic Screening
Item A, Numbers 1 through 6
Check ?Normal? or ?Abnormal? for each component. Check
						  ?Counseled,? ?Treated? or ?Referred? as applicable.
Item A, Number 7
Give results of the lab tests performed at the time of
						  screen.
Item B
Immunization status appropriate for age and health
						  history. If immunization cannot be performed, note the reason along with the
						  return appointment in ?Comments? section.
Item C
Enter any other services rendered.
21. Comments
Briefly explain any problems identified and describe
						  treatment or referral. If referred, indicate the name of the provider to whom
						  the referral was made.
22. A. Date of Service
Enter the ?from? and ?to? dates of service for each
						  service provided in MM/DD/YY format. A single date of service need not be
						  entered twice on the same line.
B. Place of Service
Enter the appropriate place of service code. See
						  Section 242.200 for codes.
C. Fully Describe Procedures, Medical Services or
						  Supplies Furnished For Each Date Given
(Explain Unusual Services or
						  Circumstances)
Enter the appropriate HCPCS, CPT and state assigned
						  procedure code and describe any services or circumstances, e.g., what age
						  periodicity screen has been provided and describe procedures performed
						  (including screen, lab test, immunizations, etc.).
Procedure Code (Identify)
D. Diagnosis Code
Enter the ICD-9-CM code, which corresponds with the
						  procedures performed.
E. Charges
Enter the charges for the rendered services. These
						  charges should be the provider?s current usual and customary fee to private
						  clients.
F. Days or Units
Enter days or units of service rendered.
G. Performing Provider Number
If the billing provider noted in Block 13 is a clinic
						  or group, enter the attending provider?s provider identification number and
						  taxonomy code.
23. Total Charges
Enter the total of Column 22E. This block should
						  contain a sum of charges for all services indicated on the claim form.
24. Covered by Insurance
Enter the total amount of funds received from other
						  sources. The source of payment should be indicated in Block 14. If payment was
						  received from the patient, indicate in Block 14, but DO NOT include the amount
						  in Block 24.
25. Balance Due
Enter the net charge. This amount is obtained by
						  subtracting the amount received from other sources from the total
						  charge.
26. Provider?s Signature
The provider or designated authorized individual must
						  sign the claim 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, 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.
27. Billing Date
Enter date signed.
Instructions for Completion of Request for
				Extension of Benefits ? DMS-699 (Rev.4/07)
All Required Fields of Form DMS-699 Must be
				Correctly Completed by Entering
The Following
				Information
Enter Provider Name, Address, City, State, Zip Code ?
REQUIRED
Enter Patient?s Full Name ?
REQUIRED
Enter Patient?s Address, City, State, Zip Code ? If
				Available
Enter Patient?s Arkansas Medicaid ID Number, Birth Date, and
				Sex ?
REQUIRED
Enter Diagnoses -Primary to Request First- Then Additional if
				Applicable ?
REQUIRED
Enter Correct Medicaid Procedure Code for Items Requested for
				Extension ?
REQUIRED
Enter Correct ?Type of Service Code? or
All Applicable
				Modifiers (After 07/01/07)
?
REQUIRED
Enter From Date of Service ?
REQUIRED
Enter To Date of Service ?
REQUIRED
Enter Correct Number of Units Being Requested ?
REQUIRED
Enter Provider ID Number ?
REQUIRED
Enter Provider Taxonomy Code - if Applicable
Complete with an Original Signature by Provider or Provider?s
				Authorized Representative -
REQUIRED
ATTACH A SUMMARY AND MEDICAL RECORDS AS NEEDED TO JUSTIFY
				MEDICAL NECESSITY ?
REQUIRED
Field Name and Number
Instructions for Completion
C. Fully Describe Procedures, Medical Services or
						  Supplies Furnished For Each Date Given
(Explain Unusual Services or
						  Circumstances)
Enter the appropriate HCPCS, CPT and state assigned
						  procedure code and describe any services or circumstances, e.g., what age
						  periodicity screen has been provided and describe procedures performed
						  (including screen, lab test, immunizations, etc.).
Procedure Code (Identify)
D. Diagnosis Code
Enter the ICD-9-CM code, which corresponds with the
						  procedures performed.
E. Charges
Enter the charges for the rendered services. These
						  charges should be the provider?s current usual and customary fee to private
						  clients.
F. Days or Units
Enter days or units of service rendered.
G. Performing Provider Number
If the billing provider noted in Block 13 is a clinic
						  or group, enter the attending provider?s provider identification number and
						  taxonomy code.
23. Total Charges
Enter the total of Column 22E. This block should
						  contain a sum of charges for all services indicated on the claim form.
24. Covered by Insurance
Enter the total amount of funds received from other
						  sources. The source of payment should be indicated in Block 14. If payment was
						  received from the patient, indicate in Block 14, but DO NOT include the amount
						  in Block 24.
25. Balance Due
Enter the net charge. This amount is obtained by
						  subtracting the amount received from other sources from the total
						  charge.
26. Provider?s Signature
The provider or designated authorized individual must
						  sign the claim 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, 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.
27. Billing Date
Enter date signed.
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InstruInsctions for Completion of Prior Authorization
				Request for Medical Equipment Form SECTION A - TO BE COMPLETED BY THE
				PROVIDER
REVIEW TYPE:
Indicate the type of prior authorization request:
						  initial, recertification, modification to a current authorization, or extension
						  of benefits.
DATE(S) OF SERVICE REQUESTED:
Enter the requested date(s) of service.
PROVIDER INFORMATION:
Enter the provider name, address, provider
						  identification number and taxonomy code, telephone number, and contact
						  person.
PATIENT INFORMATION:
Enter the beneficiary's full name (Last, First, MI),
						  ten-(10) digit Medicaid ID number, mailing address, date of birth (MM/DD/YYYY),
						  and sex (male or female).
PHYSICIAN INFORMATION:
Enter the prescribing physician's name, provider
						  identification number, and taxonomy code.
PROCEDURE CODES:
List all procedure codes (including any modifier(s) for
						  items ordered that require authorization. (Procedure codes that do not require
						  authorization should not be listed.) Enter the number of units requested and a
						  narrative description for each item ordered.
PERSON SUBMITTING REQUEST:
The person submitting the request must sign and date,
						  verifying the attestation in this section.
SECTION B - TO BE COMPLETED BY THE
				PHYSICIAN
EST. LENGTH OF NEED:
Enter the estimated length of need (the length of time
						  the physician expects the patient to require use of the ordered item) by
						  filling in the appropriate number of weeks or months or indicate permanent if
						  the physician expects that the patient will require the item for the duration
						  of his/her life.
EPSDT REFERRAL:
If applicable, indicate if the request is being made as
						  the result of an EPSDT referral.
HEIGHT & WEIGHT:
Enter the beneficiary?s current height measured in
						  inches and weight measured in pounds.
DIAGNOSIS & ICD-9 CODES:
In the first space, list the diagnosis & ICD9 code
						  that represents the primary reason for ordering this item. List any additional
						  diagnosis & ICD9 codes that would further describe the medical need for the
						  item (up to 3 codes).
QUESTION SECTION:
Answer the question by checking the appropriate ?YES?
						  or ?NO? box.
MEDICAL NECESSITY:
The physician must document medical necessity for the
						  requested services and sign/date in the space indicated. Signature and date
						  stamps are not acceptable.
**PRESCRIPTION:
A written prescription MUST be submitted with all
						  requests. This can be documented on the request form or a separate prescription
						  may be attached.
**LETTER OF MEDICAL NECESSITY:
If the information provided on the request form is
						  insufficient to justify the requested items, a letter of medical necessity from
						  the prescribing physician WILL be required.
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Note: Attach copies of Medical Records/Supporting Documentation
				substantiating
medical necessity
of requested
				services/procedures.
[Instructions for requesting extension of benefits and
				completion of this form are included on the reverse side of this form.]
				Comments:
Requirements for Requests for Extension of Benefits for
				Clinical, Outpatient, Laboratory and X-Ray Services
Procedural Policy
To reduce delays in processing requests and to avoid
				returning requests due to incomplete and/or lack of
documentation, the following procedures must be
				followed.
I. Requests for
			 extension of benefits will be considered after a claim has been denied for
			 exceeding the benefit limit.
II.
			 The Request for Extension of Benefits for Clinical, Outpatient, Laboratory and
			 X-Ray Services (Form DMS-671) must be filed within 90 calendar days of the date
			 of denial. Any request filed beyond the 90 calendar day deadline will be
			 denied.
III. Extension of benefits
			 will be denied if the original claim was denied for untimely filing (12 months
			 beyond the date of service).
IV.
			 AFMC EOB Review will consider extending benefits if
all
of the following documentation is received with request.
A.
All fields of form DMS-671 must be
			 correctly completed by entering the following information:
(1) Enter performing provider?s
			 name.
(2) Enter the provider ID #
			 and taxonomy code of performing provider.
(3) Enter the address provider will use to
			 receive correspondence regarding this extension.
(4) If the provider is a member of a group,
			 enter the group provider ID #.
(5)
			 Performing provider?s signature and credentials must be entered in this
			 field.
(6) Enter the beneficiary?s
			 full name.
(7) Enter the
			 beneficiary?s complete address.
(8)
			 Enter the beneficiary?s Medicaid ID #.
(9) Enter the beneficiary?s date of birth and
			 sex.
(10) Enter the service from
			 date ? claims for reimbursement must be filed in chronological order.
(11) Enter the service to date ? dates of
			 service must be listed in chronological order.
(12) Enter the type of service code (if claim
			 was filed on paper prior to 07-01-07 ). Type of Service codes are indicated in
			 the field directly preceding the billed procedure code on each Medical
			 Assistance Remittance and Status Report.
(13) Enter the diagnosis code.
(14) Enter the diagnosis code
			 description.
(15) Enter the
			 procedure code and applicable modifier(s). (If there are more than 4
			 procedures, additional procedures must be added to a separate completed
			 form.)
(16) Enter the procedure
			 code description.
(17) Enter the
			 number of units.