Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.08-032 - Section V Provider Manual Update Transmittal

Current through Register Vol. 49, No. 6, June, 2024
Section V
Claim Forms
Red-inkClaim Forms
The following is a list of the red-ink claim forms required by
				Arkansas Medicaid. The forms below cannot be printed from this manual for use.
				Information about where to get the forms and links to samples of the forms are
				available below. To view a sample 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
* For dates of service after 11/30/07 - ALL HOSPICE PROVIDERS
				USE ONLY FORM CMS-1450 (formerly (UB-04) for billing.
** A printable
PROVIDER INTEROFFICE DOCUMENTATION ONLY
version of this form is available below under Arkansas Medicaid
				Forms.
Claim Forms
The following is a list of the non-red-ink claim forms required
				by Arkansas Medicaid. Information about where to get a supply of the forms and
				links to samples of the forms are available below. To view a sample form, click
				the form name.
Claim Type
Where To Get Them
Alternatives Attendant Care Provider Claim Form
						  -AAS-9559
Client Employer
Dental - ADA-J400
Business Form Supplier
Arkansas Medicaid Forms
The forms below can be printed from this manual for use.
In order by form name:
Form Name
Form Number
Acknowledgement of Hysterectomy Information
DMS-2606
Address Change Form
DMS-673
Adjustment Request Form - Medicaid XIX
EDS-AR-004
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
Change of Ownership Information
DMS-0688
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
Contact Lens Prior Authorization Request
						  Form
DMS-0101
Contract to Participate in the Arkansas Medical
						  Assistance Program
DMS-653
DDTCS Transportation Log
DMS-638
DDTCS Transportation Survey
DMS-632
Dental Treatment Additional Information
DMS-32-A
Disclosure of Significant Business
						  Transactions
DMS-689
Disproportionate Share Questionnaire
DMS-628
Early and Periodic Screening, Diagnosis and Treatment
						  (EPSDT) Prescription/Referral For Medically Necessary Services/Items Not
						  Specifically Included in the Medicaid State Plan
DMS-693
Early Childhood Special Education Referral
						  Form
ECSE-R
EPSDT 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
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
Ownership and Conviction Disclosure
DMS-675
Personal Care Assessment and Service Plan
DMS-618
Practitioner Identification Number Request
						  Form
DMS-7708
Prescription & Prior Authorization Request For
						  Nutrition Therapy & Supplies
DMS-2615
Primary Care Physician Managed Care Program Referral
						  Form
DMS-2610
Primary Care Physician Participation
						  Agreement
DMS-2608
Primary Care Physician Selection and Change
						  Form
DMS-2609
Prior Authorization (PA) Request for Extension of
						  Benefits-Prescription Drugs
DMS-0685-14
Procedure Code/NDC Detail Attachment Form
DMS-664
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 Data Sharing Agreement- Medicare Parts C &
						  D
DMS-652-A
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-2606
DMS-602
DMS-650
DMS-699
AAS-9565
DMS-2608
DMS-612
DMS-651
DMS-7708
Address
DMS-2609
DMS-615
DMS-652
DMS-831
Change
DMS-2610
DMS-616
DMS-652-A
ECSE-R
AFMC-101
DMS-2615
DMS-618
DMS-653
EDS-AR-004
AFMC-102
DMS-2618
DMS-619
DMS-664
EDS-CI-003
AFMC-103
DMS-2633
DMS-628
DMS-671
EDS-CR-002
AFMC-RBSS
DMS-2634
DMS-630
DMS-675
EDS-MFR-001
Authorization for Automatic
DMS-2635
DMS-632
DMS-673
MAP-8
Deposit
DMS-2647
DMS-633
DMS-679
Report
CMS-485
DMS-2685
DMS-635
DMS-683
Provider
CSPC-EPSDT
DMS-2687
DMS-638
DMS-686
Enrollment
DCO-645
DMS-2692
DMS-640
DMS-689
Application and Contract
DDS/FS#0001.a
DMS-2698
DMS-646
DMS-693
Package
DMS-0101
DMS-32-A
DMS-647
DMS-694 chart
PUB-019
DMS-0685-14
DMS-32-0
DMS-648
version
PUB-020
DMS-0688
DMS-601
DMS-649
DMS-694 sample
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 Department of Human Services - Aging and
				Adult Services
Arkansas Department of Human Services - Appeals and
				Hearings Section
Arkansas Department of Human Services, Child Care
				and Early Childhood Education, Child Care Licensing Unit
Arkansas Department of Human Services, Children and
				Family Services, Contracts Management Unit
Arkansas Department of Human Services, Children's
				Services
Arkansas Department of Human Services, County
				Operations - Customer Assistance Section
Arkansas Department of Human Services, Medical
				Services
Arkansas Department of Human Services, Medical
				Services, Dental Care Unit
Arkansas Department of Human Services, Medical
				Services Director
Arkansas Department of Human Services, Medical
				Services, Financial Activities Unit
Arkansas Department of Human Services, Medical
				Services, Hearing Aid Consultant
Arkansas Department of Human Services, Medical
				Services, Medical Assistance Unit
Arkansas Department of Human Services, Medical
				Services, Pharmacy Unit-Utilization Review Section
Arkansas Department of Human Services, Medical
				Services, Program Communications Unit
Arkansas Department of Human Services, Medical
				Services, Third-Party Liability Unit
Arkansas Department of Human Services, Medical
				Services, UR Benefit Extension Reguests Section
Arkansas Department of Human Services, Medical
				Services, UR/Home Health Extensions
Arkansas Department of Human Services, Medical
				Services, Utilization Review Section
Arkansas Department of Human Services, Medical
				Services, Visual Care Coordinator
Arkansas Department of Human Services, Medical
				Services, Provider Reimbursement Unit
Arkansas Department of Health
Arkansas Department of Health, Health Facility
				Services
Arkansas Department of Human Services, Accounts
				Receivable
Arkansas Foundation For Medical
				Care
Arkansas Hospital Association Contact
				Information
Arkansas Medicaid Provider Enrollment
				Unit
ARKids First-B ID Card Example
ARKids First-B Telephone Number
Child Health Services
(EPSDT)
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 - Arkansas
				Department 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
QSource of Arkansas
Select Optical
Standard Register
Table of Desirable Weights
U.S. Government Printing Office
Vendor Performance
				Report