016.05.18 Ark. Code R. § 003 - Summary of the Occupational Therapy, Physical Therapy, and Speech Thereapy Provider Manual
A school district, education service cooperative, Eariy
intervention Day Treatment (EIDT) program or Adult Developmental Day Treatment
(ADDT) program may contract with or employ qualified therapy practitioners.
Effective for dates of service on and after October 1, 2008, the individual
therapy practitioner who actually perfonns a service on behalf of the facility
must be identified on the claim as the performing provider when the facility
bills for that service. This action is taken in compliance with the federal
Improper Payments Information Act of 2002 (IPIA),
Public
Law
If a facility contracts with a qualified therapy practitioner, the criteria for group providers of therapy services apply (See Section 201.100 of the Occupational, Physical. Speech Therapy Services manual). The qualified therapy practitioner who contracts with the facility must be enrolled with Ar1[LESS THAN]ansas Medicaid. The contract practitioner who performs a service must be listed as the performing provider on the claim when the facility bills for that sen/ice.
If a facility employs a qualified therapy practitioner, that practitioner has the option of either enrolling with Arkansas Medicaid or requesting a Practitioner Identification Number (View or print form DMS-7708K The employed practitioner who performs a service must be listed as the performing provider on the claim when the facility bills for that service.
The following requirements apply only to Arkansas school districts and education service cooperatives that employ (via a form W-4 relationship) qualified practitioners to pnDvide therapy services.
Arkansas Code § 17-100-104, as amended, makes it lawful for a person to perform speech-language pathology services without Arkansas licensure as:
All Provider Participation requirements detailed within Section 140.000 must be met. The additional documentation requirements below also apply to Occupational, Physical and Speech-Language Therapy providers:
Division of Developmental Disabilities Services (DDS) is the lead agency responsible for the general administration and supervision of the programs and activities utilized to carry out the provisions of Part C of the IDEA. First Connections is the DDS program in Arkansas that administers, monitors, and canies out all Part C of IDEA activities and responsibilities for the state. The First Connections program ensures that appropriate eariy intervention services are available to all infants and toddlers from birth to thirty-six (36) months of age (and their families) that are suspected of having a developmental delay.
Federal regulations under Part C of the IDEA require "primary referral sources" to refer any child suspected of having a developmental delay or disability for eariy intervention services, A physical, occupational, or speech therapist Is considered a primary referral source under Part C of IDEA regulations.
Each provider must, within two (2) working days of first contact, refer all infants and toddlers fnam birth to thirty-six (36) months of age for whom there is a diagnosis or suspicion of a developmental delay or disability. The referral must be made to the DDS First Connections Central Intake Unit, which serves as the State of Arkansas's single point of entry to minimize duplication and expedite service delivery. Each provider is responsible for maintaining documentation evidencing that a proper and timely referral to First Connections has been made.
Local Education Agencies ("LEA") have the responsibility to ensure that children from ages three (3) until entry into Kindergarten who have or are suspected of having a disability under Part B of IDEA ("Part B") receive a Free Appropriate Public Education.
For further clarification related to Special Education Sen/ices refer to the DPSQA EIDT Licensure Manual.
The Arkansas Medicaid Occupational, Physical and Speech Therapy Program reimburses therapy services for Medicaid-eligible individuals under the age of 21 in the Child Health Services (EPSDT) Program.
Therapy services for individuals aged 21 and older are only covered when provided through the following Medicaid Programs; Adult Developmental Day Treatment (ADDT), Hospital/Critical Access Hospital (CAH)/End-Stage Renal Disease (ESRD), Home Health, Hospice and Physician/Independent Lab/CRN A/Radiation Therapy Center. Refer to these Medicaid provider manuals for conditions of coverage and benefit limits.
Medicaid reimbursement is conditional upon providers' compliance with Medicaid policy as stated in this provider manual, manual update transmittals and official program correspondence.
All Medicaid benefits are based on medical necessity. Refer to the Glossary for a definition of medical necessity.
Occupational therapy, physical therapy and speech-language pathology services are those services defined by applicable state and federal rules and regulations. These services are covered only when the following conditions exist:
IVIedification in the edition Medicaid has certified as cun'ent for the patient's dates of service.
To order copies from the Arl[LESS THAN]ansas Medicaid fiscal agent use Form MFR-001 - Medicaid Forms Request. View or Print the IVIedicaid Form Request H/IFR-001.
Prior authorization of extension of benefits is required when a physician prescribes more than 90 minutes of therapy per week in one or more therapy discipline(s). Retrospective review of occupational, physical and speech therapy services is required for beneficiaries under age 21 who are receiving ninety (90) minutes per week or less of therapy sen/ices in each discipline or who are receiving rehabilitation therapy after an injury, illness or surgical procedure. The purpose of all review is the promotion of effective, efficient and economical delivery of health care sen/ices.
The Quality Improvement Organization (QIO), under contract to the Medicaid Program, perfomis retrospective reviews by reviewing medical records to determine if services delivered and reimbursed by Medicaid meet medical necessity requirements. View or print QIO contact information.
Specific guidelines have been developed for occupational, physical and speech therapy retrospective reviews. These guidelines may be found in Sections 214.300 and 214.400.
Retrospective therapy review encompasses occupational therapy (OT), speech language pathology (SLP) and physical therapy (PT) services that provide evaluation and treatment for the purpose of improving function and preventing long-term disabilities in Medicaid-eligible beneficiaries under age twenty-one (21). The primary care physician (PCP) or attending physician is responsible for referring the beneficiary for these interventions. Therapeutic intervention is covered in public schools and therapy clinics. A valid prescription written and signed by the PCP or attending physician on the revised DMS-640 form is required. This prescription is valid for the length of time indicated by the physician or up to one (1) year from the date of the physician's signature.
On a calendar quarteriy basis, the Quality Improvement Organization (QIO) under contract with Arkansas Medicaid, will select and review a percentage random sample of all the therapy services billed and paid during the past three months (previous quarter) that were either (1) 90 minutes or less per week or (2) were provided pursuant to a rehabilitation diagnosis (related to an injury, illness or surgical procedure). The request for record copies is sent to each provider along with instructions for returning the records. The request asks for the child's parent/guardian name and address and lists the child's name, date of birth, Medicaid identification number, dates of services, type of therapy, date of request and a listing of the documentation required for review. The provider(s) must provide the information to the QIO within thirty (30) calendar days of the request date printed in the record request cover letter. If the requested information is not received within the thirty-(30) day timeframe, a medical necessity denial is issued.
Post payment review of therapies is a dual process: The utilization review determines whether billed services were prescribed and delivered as billed, and the medical necessity review determines whether the amount, duration and frequency of services provided were medically necessary.
Providers must send the requested record copies to the QIO. When the records are received, each record is stamped with the receipt date and entered into the computer review and tracking system. This system automatically generates a notification to the provider that the record(s) has been received. The Receipt of Requested Therapy Records letter is an acknowledgement of receipt of the record(s) only. Individual records have not been assessed for completeness of documentation. Additional documentation may be requested from the provider at a later date in order to complete a retrospective therapy review audit.
Records will not be accepted via facsimile or email.
The record is initially reviewed by a registered nurse using screening guidelines developed from the promulgated Medicaid therapy manual. The nurse reviewer screens the chart to determine whether the con-ect infonmation was submitted for review. If it is determined that the requested infonnation was submitted con-ectly, the nurse reviewer can then review the documentation in more detail to detenmine whether it meets Medicaid eligibility criteria for medical necessity. The medical necessity review includes verifying that all therapy services will be or have been provided under a valid PCP prescription (forni DMS-640). A prescription Is considered valid if it contains the following information: the child's name, Medicaid ID number, a valid diagnosis that cleariy establishes and supports that the prescribed therapy is medically necessary, minutes and duration of therapy and is signed and dated by the PCP or attending physician. All therapy prescriptions must be on the revised DMS-640 form. Rubber-stamped signatures, those signed by the physician's nurse or a nurse practitioner and those without a signature date are not considered valid. Changes made to the prescription that alter the type and quantity of services prescribed are invalid unless changes are initialed and dated by the physician.
If the guidelines are met when being retrospectively reviewed and medical necessity is approved, the nurse reviewer proceeds to the utilization portion of the review. If guidelines are not met or the prescription is invalid, the nurse reviewer refers the record to an appropriate therapist adviser for further review.
The therapist adviser may determine there is medical necessity even though the guidelines are not met, or make recommendation to the Associate Medical Director (AMD) for possible denial of all or part of the services provided. The AMD will review the recommendation and make a final decision to approve or deny. If the services are partially or completely denied, the provider, the beneficiary and the ordering physician are notified in writing of the denial. Each denial letter contains a rationale for the denial that is case specific. Each party is provided information about requesting reconsideration review or a fair hearing.
When the billed services are determined to be medically necessary during retrospective review, the nurse reviewer proceeds to the utilization portion of the review. The computer review system lists all claims for services paid during the previous quarter for each beneficiary selected. This listing includes the procedure code and modifier, if required, dates of service billed and units paid. The nurse reviewer compares the paid claims data to the progress notes submitted. The previously mentioned screening guidelines are utilized to verify that the proper procedure code and modifier, if required, were billed, time in/out is documented, a specific description of the therapy services provided, activities rendered during the therapy session and some fomi of measurement is documented for each daily therapy session along with the providing therapist's signature (full name and credentials). If the documentation submitted supports the billed services, the nurse reviewer approves the utilization portion of the retrospective review When documentation submitted does not support the billed services, the nurse reviewer refers the services not supported by documentation to an appropriate therapist for further review.
The therapist reviews the documentation and either approves the services as billed or provides a recommendation to the AMD to deny some or all of the services. If the AMD agrees with the denial, a denial letter is mailed to the provider, the ordering physician and the beneficiary. The letter includes case specific rationale explaining why the services did not meet established criteria.
Therapy Reviews may result in either a medical necessity or a utilization denial. For utilization only denials, the service provider is notified in writing of the denied services. The denial notification provides case specific rationale for the denial and will include instructions for requesting reconsideration. If the denial is for medical necessity, the PCP or attending physician and the services provider(s) will be notified in writing of the medical necessity denial. Each denial letter contains case specific denial rationale. The PCP denial letter informs the physician that a denial for therapy services on a specific Medicaid beneficiary has been issued. It states that he is being notified for information only because he might be called upon by the providers(s) to assist in the request for reconsideration. For either denial type, the provider is allowed 35 calendar days to submit additional information for reconsideration. Reconsideration review will not be performed if the additional information does not contain substantially different information than that previously submitted. Only one reconsideration is allowed per denial.
The beneficiary is notified in writing of all medical necessity denials at the same time the provider is notified. The beneficiary's denial letter includes case specific denial rationale and includes instructions for requesting a fair hearing. The beneficiary is not notified of utilization denials.
Occupational and physical therapy services must be medically necessary to the treatment of the individual's illness or injury. A diagnosis alone is not sufficient documentation to support the medical necessity of therapy. To be considered medically necessary, the following conditions must be met:
To establish medical necessity, a comprehensive assessment in the suspected area of deficit must be perfomned. A comprehensive assessment must include:
NOTE: To calculate a child's gestational age, subtract the number of weeks bom before 40 weel(s of gestation from the chronological age. Therefore, a 7-month-old. former 28 week gestational age infant has a corrected age of 4 months according to the following equation:
7 months - [(40 weeks) - 28 weeks) / 4 weeks]
7 months - [(12) / 4 weeks]
7 months - [3]
The frequency, intensity and duration of therapy services should always be medically necessary and realistic for the age of the child and the severity of the deficit or disorder. Therapy is indicated if improvement will occur as a direct result of these services and if there is a potential for improvement in the form of functional gain.
Speech-language therapy sen/ices must be medically necessary to the treatment of the individual's illness or injury. A diagnosis alone is not sufficient documentation to support the medical necessity of therapy. To be considered medically necessary, the following conditions must be met:
A speech production disorder may manifest as an individual sound deficiency, i.e.. traditional articulation disorder, incomplete or deviant use of the phonological system, i.e., phonological disorder, or poor coordination of the oral-motor mechanism for purposes of speech production, i.e., verbal and/or oral apraxia, dysarthria.
Mild: Scores between 84-78; -1.0 standard deviation Moderate: Scores between 77-71; -1.5 standard deviations Severe: Scores between 70-64; -2.0 standard deviations Profound: Scores of 63 or lower; -2.0-[LESS THAN]- standard deviations
NOTE: To calculate a child's gestational age, subtract the number of weeks born before 40 weeks of gestation from the chronological age. Therefore, a 7-month-old, former 28 week gestational age Infant has a corrected age of 4 months according to the following equation:
NOTE: To calculate a child's gestational age. subtract the number of weeks born before 40 weeks of gestation from the chronological age. Therefore, a 7-month-old, former 28 week gestational age Infant has a corrected age of 4 months according to the following equation:
NOTE: To calculate a child's gestational age, subtract the number of weeks bom before 40 weeks of gestation from the chronological age. Therefore, a 7-nionth-old, former 28 week gestational age infant has a corrected age of 4 months according to the following equation:
NOTE: To calculate a child's gestational age, subtract the number of weeks born before 40 weeks of gestation from the chronological age. Therefore, a 7-month-old, former 28 week gestational age infant has a corrected age of 4 months according to the following equation:
NOTE: To calculate a child's gestational age, subtract the number of weeks bom before 40 weeks of gestation from the chronological age. Therefore, a 7-month-old, former 28 week gestational age infant has a corrected age of 4 months according to the following equation:
Eligibility for articulation and/or phonological therapy will be based upon standard scores (SS) of -1.5 SD or greater below the mean from two tests. When -1.5 SD or greater Is not indicated by both of these tests, corroborating data derived from clinical analysis procedures can be used to support the medical necessity of services (review Section 214.410 - Accepted Tests for Speech-Language Therapy).
Eligibility for apraxia therapy will be based upon standard scores (SS) of -1.5 SD or greater below the mean from two tests. When -1.5 SD or greater is not indicated by both of these tests, corroborating data from a criterion-referenced test and/or accepted clinical can be used to support the medical necessity of services (review Section 214.410 - Accepted Tests for Speech-Language Therapy).
Eligibility for voice therapy will be based upon a medical referral for therapy and a functional profile of voice parameters that indicates a moderate or severe deficit/disorder.
Eligibility for fluency therapy will be based upon standard scores (SS) of -1.5 SD or greater below the mean from two tests. When -1.5 SD or greater is not indicated by both of these tests, descriptive data from an affect measure and/or accepted clinical procedures can be used to support the medical necessity of services. (Review Section 214.410 - Accepted Tests for Speech-Language Therapy.)
Eligibility for oral-motor/swallowing/feeding therapy will be based upon an in-depth functional profile of oral motor structures and function using a thorough protocol (e.g.. checklist, profile) that indicates a moderate or severe deficit or disorder. When moderate or severe aspiration has been confirmed by a videofluoroscopic swallow study, the patient can be treated for pharyngeal dysphagia via the recommendations set forth in the swallow study report.
The following is a step-by-step outline of the QIC's extended services review process:
A request for administrative reconsideration of the denial of sen/ices must be in writing and sent to the QIO within 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 this manual. A request received by The QIO within 35 calendar days of a denial will be deemed timely.
Communication Device (ACD) Evaluation
To perform an evaluation for the augmentative communication device (ACD), the provider must request prior authorization from the Division of Medical Sen/ices, using the following procedures.
NOTE: Prior authorization for therapy services only applies to the augmentative communication evaluation. Refer bacit to Section 215.000 for additional Information.
Services must be billed according to the care provided and to the extent each procedure is provided.
Extended therapy services may be requested for all medically necessary therapy services for beneficiaries under age 21. Refer to Sections 216 000 through 216.310 of this manual for more infomiation.
Claim Forms
Red-ink Claim Forms
The foliowing is a list of tlie red-ink claim forms required by Arl[LESS THAN]ansas Medicaid. Tfie forms below cannot be printed from tliis manual for use. Infonnation about where to get the fomris and links to samples of the forms is available below, To view a sample form, click the form name.
Claim Type |
Where To Get Them |
Professional - CMS-1500 |
Business Forni Supplier |
Institutional - CMS-1450* |
Business Form Supplier |
* For dates of sen/ice after 11/30/07 - ALL HOSPICE PROVIDERS USE ONLY FORM CMS-1450 (fomierly UB-04) for billing.
Claim Forms
The following is a list of the non-red-ink claim forms required by Arkansas Medicaid. Infonnation about where to get a supply of the forms and links to samples of the fornis is available below. To view a sample fonn, click the fomi name.
Claim Type |
Where To Get Them |
Alternatives Attendant Care Provider Claim Form - |
Client Employer |
AAS-9559 |
|
Dental - ADA-J430 |
Business Form Supplier |
Arkansas Medicaid Forms
The fonns below can be printed from this manual for use.
In order by form name:
Form Name |
Form Link |
Acknowledgement of Hysterectomy Information |
DMS-2606 |
Address/Email Change Form |
DMS-673 |
Adjustment Request Forni - Medicaid XIX |
HP-AR.004 |
Adjustment Request Form - Medicaid XIX - Phamnacy Program |
DMS-802 |
Adverse Effects Fomi |
DMS-2704 |
AFMC Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components |
DMS-679A |
Amplification/Assistive Technology Recommendation Form |
DIVIS-686 |
Application for WebRA Hardship Waiver |
DMS-7736 |
Approval/Denial Codes for Inpatient Psychiatric Services |
DMS-2687 |
Arkansas Early Intervention Infant & Toddler Program Intake/Referral/Apptication for Services |
DDS/FS#0001.a |
Arkansas Medicaid Patient-Centered Medical Home Program Practice Participation Agreement |
DMS-844 |
Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Fomn |
DMS-84S |
Arkansas Medicaid Patient-Centered Medical Home Program Practice Withdrawal Fonn |
DMS-846 |
ARKids First Behavioral Health Services Provider Qualification Form |
DMS-612 |
Authorization for Electronic Funds Transfer (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 |
Child Health Management Services Enrollment Orders |
DMS-201 |
Child Health Management Services Discharge Notification Form |
DMS-202 |
CHMS Benefit Extension for Diagnosis/Evaluation Procedures |
DMS-699A |
CHMS Request for Prior Authorization |
DMS-102 |
Claim Correction Request |
DMS-2647 |
CMS 1500/UB04 Medicare EOMB Information (Crossover Cover Sheet) |
DMS-600 |
Consent for Release of Information |
DIVIS-619 |
Contact Lens Prior Authorization Request Form |
DMS-0101 |
Contract to Participate in the Arkansas Medical Assistance Program |
DMS-653 |
EIDT/ADDT Transportation Log |
DMS-638 |
EIDT/ADDT Transportation Sun/ey |
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 Provider Agreement |
DMS-831 |
Evaluation for Wheelchair and Wheelchair Seating |
DMS-0843 |
Explanation of Check Refund |
HP-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 |
Individual Renewal Form for School-Based Audiologists |
DMS-7782 |
Lower-Limb Prosthetic Evaluation |
DMS-650 |
Lower-Limb Prosthetic Prescription |
DMS-651 |
Media Selection/Email Address Change Form |
HP-MS-005 |
Medicaid Claim Inquiry Form |
HP-CI-003 |
Medicaid Form Request |
HP-MFR-001 |
Medical Equipment Request for Prior Authorization & Prescription |
DMS-679 |
Medical Transportation and Personal Assistant Verification |
DMS-616 |
Mental Health Sen/ices 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-618Enatish DMS-618 Spanish |
Practitioner Identification Number Request Form |
DMS-7708 |
Prescription & Prior Authorization Request For Nutrition Therapy & Supplies |
DMS.2615 |
Primary Care Physician Managed Care Program Referral Fonn |
DMS-2610 |
Primary Care Physician Participation Agreement |
DMS-2608 |
Primary Care Physician Selection and Change Form |
DMS-2609 |
Procedure Code/NDC Detail Attachment Fomn |
DA/IS-664 |
Provider Application |
DMS-652 |
Provider Communication Fomi |
AAS.9502 |
Provider Data Sharing Agreement - Medicare Parts C & D |
DMS-652-A |
Provider Enrollment Application and Contract Package |
ADDtication Packet |
Quarteriy Monitoring Form |
AAS-9506 |
Referral for Audiology Services - School-Based Setting |
DMS-7783 |
Referral for Certification of Need Medicaid Inpatient Psychiatric Services for Under Age 21 |
DMS-2634 |
Referral for Medical Assistance |
DMS-630 |
Request for Appeal |
DMS-840 |
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 Molecular Pathology Laboratory Services |
DMS-841 |
Request for Orthodontic Treatment |
DMS-32-0 |
Request for Prior Approval for the Special Phanmacy Therapeutic Agents and Treatments |
DMS-6 |
Request for Private Duly 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 |
Research Request Form |
HP-0288 |
Service Log - Personal Care Delivery and Aides Notes |
DMS-873 |
Sterilization Consent Form |
DM5-615 Enalish DMS-615SDanish |
Sterilization Consent Form - Information for Men |
PUB-020 |
Sterilization Consent Form - Information for Women |
PUB-019 |
Targeted Case Management Contact Monitoring Form |
DMS-690 |
Upper-Limb Prosthetic Evaluation |
DMS-648 |
Upper-Limb Prosthetic Prescription |
DMS-649 |
Vendor Performance Report |
VendorDerformreport |
Verification of Medical Services |
DMS-2618 |
In order by form number:
AAS-9502 |
AAS-9506 |
AAS-9559 |
Address |
Chanqe |
Autodeposit |
CMS-485 |
CSPC-EPSDT |
DCO-645 |
DDS/FS#0001.a |
DMS-0101 |
DMS-0688 |
OMS-0843 |
DMS'102 |
DMS-201 |
DMS-202 |
DMS-2606 |
DMS-2608 |
DMS'2609 |
DMS-2610 |
DMS-2615 |
DMS-2618 |
DMS-2633 |
DMS-2634 |
DMS-2647 |
DMS-2685 |
DMS-2687 |
DMS-2e92 |
DMS-2698 |
DMS-2704 |
DMS-32-A |
DMS-32-0 |
OMS-6 DMS-600 |
DMS-601 |
DMS-602 |
DMS-612 |
OMS-615 |
English |
DMS-615 |
Spanish |
DMS-616 |
DMS-618 |
Enqlish |
DMS-618 |
Spanish |
DMS-619 |
DMS-628 |
OIVIS-630 |
DIVIS-632 |
DMS-633 |
DIVIS-635 |
DMS-638 |
DMS-640 |
DMS-647 |
DIVIS-648 |
DIVIS-649 |
DIVIS-650 |
DMS-651 |
DIMS-652 |
DIVIS-652-A |
OMS-653 |
DMS-664 |
DiVIS-671 |
DMS-675 |
DIVIS-673 |
DIVIS-679 |
DIVIS-679A |
DMS-683 |
DIVIS-686 |
DMS-689 |
Divis-ego |
DIVIS-693 |
DiVI 3-699 |
DIVIS-699A |
DMS-7708 |
DIWS-7736 |
DIV1S.7782 |
DiVIS-7783 |
DMS-802 |
DIVIS-831 |
DMS-840 |
DMS-841 |
DMS-844 |
DIVtS-845 |
DIUIS-846 |
DMS-873 |
ECSE-R |
HP-0288 |
HP-AR-004 |
HP-CI-003 |
HP-CR-002 |
HP-MFR-001 |
HP-MS-005 |
1V1AP-8 Performance |
Report |
Provider |
Enrollment |
Application |
and Contract |
Packaae |
PUB-019 |
PUB-020 |
Arkansas Medicaid Contacts and Links Click the link to view the infonnation.
American Hospital Association
Americans with Disabilities Act Coordinator
Arkansas Department of Education. Health and Nursing Services Specialist
Arkansas Department of Education. Special Education
Arkansas Department of Finance Administration. Sales and Tax Use Unit
Arkansas Department of Human Services. Division of Aging and Adult Services
Arkansas Department of Human Services. Appeals and Hearings Section
Arkansas Department of Human Services. Division of Behavioral Health Services
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 Department of Human Services. Children's Services
Arkansas Department of Human Services. Division of County Operations. Customer Assistance Section
Arkansas Department of Human Services. Division of IVIedical Services
Arkansas DHS. Division of Medical Services Director
Arkansas DHS. Division of Medical Services. Benefit Extension Requests. UR Section
Arkansas DHS. Division of Medical Services. Dental Care Unit
Arkansas DHS. Division of Medical Services. DXC Technology Provider Enrollment Unit
Arkansas DHS. Division of Medical Services. Financial Activities Unit
Arkansas DHS. Division of Medical Services. Hearing Aid Consultant
Arkansas DHS. Division of Medical Services. Medical Assistance Unit
Arkansas DHS. Division of Medical Services, Medical Director for Clinical Affairs
Arkansas DHS. Division of Medical Services. Pharmacy Unit
Arkansas DHS. Division of Medical Services. Program Communications Unit
Arkansas DHS. Division of Medical Services. Provider Reimbursement Unit
Arkansas DHS. Division of Medical Services. Third-Party Liability Unit
Arkansas DHS. Division of Medical Services. UR/Home Health Extensions
Arkansas DHS. Division of Medical Services. Utilization Review Section
Arkansas DHS. Division of Medical Services. Visual Care Coordinator
Arkansas Department of Health
Arkansas Department of Health. Health Facility Services
Arkansas Department of Human Services. Accounts Receivable
Arkansas Foundation for Medical Care
Arkansas Foundation for Medical Care. Retrospective Review for Therapy and Prior Authorization for Personal Care for Under Age 21
Arkansas Foundation for Medical Care. Provider Relations Representative
Arkansas Hospital Association
Arkansas Office of Medicaid Inspector General (OMIG)
ARKids First-B
ARKids First-B ID Card Example
Beacon Health Options (Formerly ValueOptions)
Central Child Health Services Office (EPSDT)
ConnectCare Helpline
County Codes
Dental Contractor
DXC Technology Claims Department
DXC Technology EDI Support Center (formerly AEVCS Help Desk)
DXC Technology Inguirv Unit
DXC Technology Manual Order
DXC Technology Provider Assistance Center iPAC)
DXC Technology Supplied Forms
Example of Beneficiary Notification of Denied ARKids FJrst-B Claim
Example of Beneficiary Notification of Denied Medicaid Claim
First Connections Infant & Toddler Program. Developmental Disabilities Services
First Connections Infant & Toddler Program. Developmental Disabilities Services. Appeals
Flow Chart of Intake and Prior Authorization Process For Intervention/Treatment
Health Care Declarations
Immunizations Registry Help Desk
Magellan Pharmacy Call Center
Medicaid ID Card Example
Medicaid Managed Care Services (MMCS)
Medicaid Reimbursement Unit Communications Hotline
Medicaid Tooth Numbering System
National Supplier Clearinghouse
Partners Provider Certification
Primary Care Physician (PCP) Enrollment Voice Response System
Provider Qualifications. Division of Behavioral Health Services
Select Optical
Standard Register
Table of Desirable Weights
U.S. Government Printing Office
Vendor Performance Report
Arkansas Division of Medical Services EIDT/ADDT Transportation Survey
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Instructions for Completion
Form DMS-640 -Therapy and Habilitation Services for Medicaid Eligible Beneficiaries PRESCRIPTION/REFERRAL
* If the DMS-640 is used to make an initial referral for evaluation, check the box to indicate the appropriate therapy for the referral. 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.
* Return To - To be completed by requesting provider(s) to include providers' address/fax/secure email.
Physician or Physician's office staff must complete the following:
* Date Beneficiary Was Last Seen In Office Enter the date of the last time you saw this beneficiary. (This could be either for a complete physical examination, a routine check-up or an office visit for other reasons requiring your personal attention.)
* Diagnosis as Related to Prescribed Therapy - 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 lime, check the box.
* Settings and Duration-Indicate the settings where therapy should occur and the duration of therapy expected to occur in that setting per week.
* Other Information/Medical necessity justification for more than 90 minutes per week Any other information pertinent to the beneficiary's medical condition, plan of treatment, etc., may be entered. If you are requesting a prior authorization for more than 90 minutes per week, please include any written justification here.
* Primary Care Physician (PCP) Name and Provider ID Number and/or Ta.xonomy Code Print the name of the prescribing PCP and his or her provider identification number and/or taxonomy code.
* Attending Physician Name and Provider ID Number and or Taxonomy Code - If the Medicaid-eligible beneficiary is exempt from PCP requirements, print the name of the prescribing attending physician and his or her provider identification number and/or taxonomy code.
* Physician Signature and Date The prescribing physician must sign and date the prescription for therapy in his or her original signature.
* Arkansas Medicaid's criteria for electronic signatures as stated in Arkansas Code 25-31-103 must be met. For vendor's EHR systems that are not configurable to meet the signature criteria, the provider should print, date and sign the DMS-640 form. Providers will be in compliance if a scanned copy of the original document is kept in a forniat that can be retrieved for a specific beneficiary. Most electronic health record systems allow this type of functionality.
* When an electronic version of the DMS 640 becomes part of the physician/ or providers' electronic health record, the inclusion of extraneous patient and clinic information does not alter the form.
* When the prescription needs to be amended for one service type or setting, a new DMS-640 must be submitted. This DMS-640 must contain the services to be received by that beneficiary in all settings. Only the amended service expiration date may change.
* Only the services listed on the most recent DMS-640 will be authorized to be provided.
The original of the completed form DMS-640 must be maintained in the beneficiary's medical records by the prescribing physician. A copy of the completed form DMS-640 must be retained by the therapy provider(s).
ATTACHMENT 3.1-A
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
Speech-Language Pathology services and qualified Speech-Language Pathologists meet the requirements set forth in 42 CFR 440.110. Speech-Language Pathology Assistants work under the supervision of the Speech-Language Pathologist in accordance with the State's licensing and supervisory requirements.
Physical Therapy services and qualified Physical Therapists meet the requirements set forth in 42 CFR 440.110. Physical Therapy assistants work under the supervision of the Physical Therapist in accordance with the State's licensing and supervisory requirements.
Occupational Therapy services and qualified Occupational Therapists meet the requirements set forth in 42 CFR 440.110. Occupational Therapy assistants work under the supervision of the Occupational Therapist in accordance with the State's licensing and supervisory requirements.
Audiology services and qualified Audiologists meet the requirements set forth in 42 CFR 440.110.
Augmentative Communication Device (ACD) Evaluation - Effective for dates of service on or after September 1, 1999, Augmentative Communication Device (ACD) evaluation is covered for eligible Medicaid recipients of all ages. One ACD evaluation may be performed every three years based on medical necessity. The benefit limit may be extended for individuals under age 21.
ATTACHMENT 3.1-B
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
Speech-Language Pathology services and qualified Speech-Language Pathologists meet the requirements set forth in 42 CFR 440.110. Speech-Language Pathology Assistants work under the supervision of the Speech-Language Pathologist in accordance with the State's licensing and supervisory requirements.
Physical Therapy services and qualified Physical Therapists meet the requirements set forth in 42 CFR 440.110. Physical Therapy assistants work under the supervision of the Physical Therapist in accordance with the State's licensing and supervisory requirements.
Occupational Therapy services and qualified Occupational Therapists meet the requirements set forth in 42 CFR 440.110. Occupational Therapy assistants work under the supervision of the Occupational Therapist in accordance with the State's licensing and supervisory requirements.
Audiology services and qualified Audiologists meet the requirements set forth in 42 CFR 440.110.
Augmentative Communication Device (ACD) Evaluation - Effective for dates of service on or after September 1, 1999, Augmentative Communication Device (ACD) evaluation is covered for eligible Medicaid recipients of all ages. One ACD evaluation may be performed every three years based on medical necessity. The benefit limit may be extended for individuals under age 21.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.