Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.06-033 - Section V - Provider Manual Update Transmittal

Current through Register Vol. 49, No. 6, June, 2024
Provider Manual
Transmittal Number
Alternatives for Adults with Physical Disabilities
						  Waiver..................................................
........36
Ambulatory Surgical
						  Center.............................................................................................
........68
ARKids
						  First-B.................................................................................................................
........34
Certified
						  Nurse-Midwife....................................................................................................
........72
Child Health Management
						  Services.................................................................................
........70
Child Health Services/Early and Periodic Screening,
						  Diagnosis and Treatment..............
........76
Children's Services Targeted Case
						  Management............................................................
........22
Chiropractic......................................................................................................................
........65
DDS Alternative Community Services
						  Waiver..................................................................
........63
Dental...............................................................................................................................
........88
Developmental Day Treatment Clinic
						  Services................................................................
........72
Developmental Rehabilitation
						  Services............................................................................
........22
Division of Youth Services and Division of Children and
						  Family Services
Targeted Case
						  Management...............................................................................
........14
Domiciliary
						  Care...............................................................................................................
........50
ElderChoices Home and Community-Based 2176
						  Waiver...............................................
........64
Federally Qualified Health
						  Center....................................................................................
........59
Hearing
						  Services..............................................................................................................
........61
Home
						  Health....................................................................................................................
........79
Hospice............................................................................................................................
........51
Hospital/End-Staqe Renal
						  Disease..................................................................................
........94
Hyperalimentation............................................................................................................
........77
Inpatient Psychiatric Services for Under Age
						  21..............................................................
........70
Licensed Mental Health
						  Practitioners...............................................................................
........54
Living Choices Assisted
						  Living.........................................................................................
........20
Medicare/Medicaid Crossover
						  Only.................................................................................
........47
Nurse
						  Practitioner............................................................................................................
........68
Occupational, Physical, Speech Therapy
						  Services..........................................................
........61
Personal
						  Care..................................................................................................................
........74
Pharmacy.........................................................................................................................
........87
Provider Manual
Transmittal Number
Physician/Independent Lab/CRNA/Radiation Therapy
						  Center.....................
..........................115
Podiatrist......................................................................................................
.............................67
Portable X-Ray
						  Services..............................................................................
.............................56
Private Duty Nursinq
						  Services.....................................................................
.............................67
Prosthetics...................................................................................................
.............................79
Rehabilitative
						  Hospital..................................................................................
.............................64
Rehabilitative Services for Persons with Mental
						  Illness...............................
............................69
Rehabilitative Services for Persons with Physical
						  Disabilities......................
............................42
Rehabilitative Services for Youth and
						  Children............................................
............................24
Rural Health Clinic
						  Services.........................................................................
.............................59
School-Based Mental Health
						  Services.........................................................
............................27
Tarqeted Case
						  Manaqement.......................................................................
.............................60
Transportation..............................................................................................
.............................79
Ventilator
						  Equipment....................................................................................
.............................61
Visual
						  Care..................................................................................................
.............................75
REMOVE
INSERT
Section
Date
Section
Date
DMS-640
8/05
DMS-640
7/06
Explanation of
				Updates
Form DMS-640 has been revised to reflect the expenditure data
				for state fiscal year (SFY) 2005.
Paper versions of this update transmittal have updated pages
				attached to file in your provider manual. See Section I for instructions on
				updating the paper version of the manual. For electronic versions, these
				changes have already been incorporated.
If you need this material in an alternative format, such as
				large print, please contact our Americans with Disabilities Act Coordinator at
				(501) 682-6789 (TDD only).
If you have questions regarding this transmittal, please
				contact the EDS Provider Assistance Center at 1-800-457 -4454 (Toil-Free)
				within Arkansas or locally and Out-of-State at (501) 376-2211.
Arkansas Medicaid provider manuals (including update
				transmittals), official notices and remittance advice (RA) messages are
				available for downloading from the Arkansas Medicaid website:
				www.medicaid.state.ar.us.
Thank you for your participation in the Arkansas Medicaid
				Program.
Click here
				to view image
I nstructions for
				Completion
Form DMS-640 - Occupational, Physical and Speech Therapy
				for Medicaid Eligible Beneficiaries Under Age 21 PRESCRIPTION
				/REFERRAL
* If DMS-640 is used to make an initial referral for
				evaluation, check the referral box only. After receiving the evaluation results
				and determining that therapy is necessary, you must use a separate DMS-640 form
				to prescribe the therapy. Check the treatment box for prescription and complete
				the form following the instructions below. If the referral and prescription are
				for previously prescribed services, you may check both boxes.
* Patient Name - Enter the patient's full name.
* Medicaid ID # - Enter the patient's Medicaid ID number.
Physician/Physician's office staff must complete the
				following:
* Date Child Was Last Seen In Office - Enter the date of the
				last time you saw this child. (This could be either for a complete physical
				examination, a routine check-up or an office visit for other reasons requiring
				your personal attention.)
* Primary Diagnosis - Enter the primary medical diagnosis
				description or ICD-9 diagnosis code.
* Diagnosis as Related to Prescribed Treatment - Enter the
				diagnosis that indicates or establishes medical necessity for prescribed
				therapy.
* Prescription block - If the form is used for a prescription,
				enter the prescribed number of minutes per week and the prescribed duration (in
				months) of therapy.
* If therapy is not medically necessary at this time, check the
				box.
* Other Information - Any other information pertinent to the
				child's medical condition, plan of treatment, etc., may be entered.
* Primary Care Physician (PCP) Name and Medicaid Provider
				Number - Print the name of the prescribing PCP and his or her Medicaid provider
				number.
* Attending Physician Name and Medicaid Provider Number - If
				the Medicaid-eligible child is exempt from PCP requirements, print the name of
				the prescribing attending physician and his or her Medicaid provider
				number.
* Physician Signature and Date - The prescribing physician must
				sign and date the prescription for therapy in his or her original
				signature.
*These therapy amounts include therapy provided in a
				Developmental Day Treatment Center (DDTCS)
The original of the completed form DMS-640 must be maintained
				in the child's medical records by the prescribing physician. A copy of the
				completed form DMS-640 must be retained by the therapy
				provider.