Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.05-033 - Provider Manual Update Transmittal - Section V

Current through Register Vol. 49, No. 6, June, 2024
Section V
Claim Forms
Red-ink Claim Forms
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 on 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
Outpatient Crossover - EDS-MC-003
EDS - 1-800-457 -4454
Professional Crossover - EDS-MC-004
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
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 on the form name.
Claim type
Where to get them
Alternatives Attendant Care Provider
						  Claim Form -AAS-9559
Client Employer
Dental - ADA-J510
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.
Form Name
Form Number
Acknowledgement of Hysterectomy Information
DMS-2606
Address Change Form
None
Adjustment Request Form - Medicaid XIX
EDS-AR-004
AFMC CHMS Request for Prior Authorization
CHMS-PA
AFMC Personal Care Assessment and Service Plan for
						  Medicaid Recipients Under Age 21
AFMC-201
AFMC Request For Bilaminate Skin Substitutes
AFMC-RBSS
AFMC Request for Occupational, Physical, and Speech
						  Therapy Prior Authorization for Medicaid Recipients Under Age 21
AFMC-401
Agreement Between Parent(s) and Respite
						  Caregiver
RC-A
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
Arkansas Medicaid Provider Application and
						  Contract
DMS-652
ARKids First Mental Health Services Provider
						  Qualification Form
DMS-612
Assisted Living Waiver Plan of Care
AAS-9565
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 or
						  Specified Treatment Procedures
CHMS-DET
CHMS Benefit Extension for Diagnosis/Evaluations or
						  Treatment
DMS-625
CHMS Benefit Extension for Occupational, Physical and
						  Speech Therapy Services
DMS-629
Claim Correction Request
DMS-2647
Children's Services Respite Care Waiver Level of
						  Functioning Survey for the Mentally Retarded/Developmentally Disabled Summary
						  Sheet
DMS-666
Children's Services Respite Care Waiver Level of
						  Functioning Survey for the Physically Disabled Summary Sheet
DMS-667
Consent for Release of Information
DMS-619
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 Provider Agreement
EPSDT-PA
Evaluation Form Lower-Limb
DMS-646
Explanation of Check Refund
EDS-CR-002
Family Friends Children's Services Respite Care Waiver
						  Freedom of Choice and Fair Hearing
DMS-669
Family Friends Children's Services Respite Care Waiver
						  Plan of Care
DMS-661
Family Friends Respite Care Application Form For
						  Families
DMS-851
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
Occupational, Physical and Speech Therapy for Medicaid
						  Eligible Recipients Under Age 21 Prescription/Referral
DMS-640
Personal Care Assessment and Service Plan
DMS-618
Primary Care Physician Managed Care Program Referral
						  Form
DMS-2610
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 Communication Form
AAS-9502
Referral for Certification of Need Medicaid Inpatient
						  Psychiatric Services for Under Age 21
DMS-2634
Referral for Medical Assistance
DMS-630
Request for Approval
DMS-617
Request for Authorization of Child Health Management
						  Services
DMS-624
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 Recipients Under Age 21
DMS-602
Request For Orthodontic Treatment
DMS-32-0
Request for Prior Authorization and Prescription for
						  Hyperalimentation
DMS-2615
Request for Private Duty Nursing Services Prior
						  Authorization and Prescription - Initial Request or Recertification
DMS-2692
Request for Speech Therapy Prior Authorization for
						  ARKids First-B Participants
DMS-623
Request for Targeted Case Management Prior
						  Authorization for Recipients Under Age 21
DMS-601
Service Agreement and Certification/Delegation of
						  Children's Services Respite Caregiver
DMS-852
Sterilization Consent Form
DMS-615
Sterilization Consent Form - Information for Men
PUB-020
Sterilization Consent Form - Information for
						  Women
PUB-019
Upper-Limb Prosthetic Prescription
DMS-649
Verification of Medical Services
DMS-2618
Arkansas Medicaid Contacts and Links
Click on the name to view the needed information.
American Hospital
				Association
Americans with Disabilities Act
				Coordinator
APS Healthcare Midwest
				(APS)
Arkansas Benefit Limits Review Committee
				Utilization Review Section
Arkansas Department of Education Special
				Education
Arkansas Department of
				Health
Arkansas Department of Health Division of
				Health Facility Services
Arkansas Department of Human Services
				Accounts Receivable
Arkansas Department of Human Services
				Children's Medical Services Family Friends CMS Respite
				Care
Arkansas Department of Human Services
				Division of Medical Services
Arkansas Department of Human Services
				Division of Medical Services, Provider Reimbursement
				Unit
Arkansas Department of Human Services,
				Division of Child Care and Early Childhood Education, Child Care Licensing
				Unit
Arkansas Department of Human Services,
				Division of Children and Family Services, Contracts Management
				Unit
Arkansas Division of Medical Services Benefit
				Extension Requests Section
Arkansas Division of Medical Services
				Director
Arkansas Division of Medical Services
				Financial Activities Unit
Arkansas Division of Medical Services Hearing
				Aid Consultant
Arkansas Division of Medical Services Medical
				Assistance Unit
Arkansas Division of Medical Services Program
				Communications Unit
Arkansas Division of Medical Services
				Third-Party Liability Unit
Arkansas Division of Medical Services UR/Home
				Health Extensions
Arkansas Division of Medical Services
				Utilization Review Section
Arkansas Division of Medical Services Visual
				Care Coordinator
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
Children's
				Services
Classical Optical
ConnectCare
				Helpline
County Codes
CPT Ordering
				Information
Department of Human Services - Appeals and
				Hearings Section
Division of Aging and Adult
				Services
Division of County Operations - Customer
				Assistance Section
Division of Medical Services Dental Care
				Unit
Division of Medical Services Pharmacy
				Unit-Utilization Review Section
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 Recipient Notification of Denied
				ARKids First-B Claim
Example of Recipient 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 and Nursing Services
				Specialist
Health Care
				Declarations
ICD-9-CM Ordering
				Information
Immunizations Data Entry
				Office
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
Standard Register
Table of Desirable
				Weights
U.S. Government Printing
				Office
Vendor Performance
				Report