016.06.06 Ark. Code R. 073 - Medicaid State Plan Amendment #2006-005

ATTACHMENT 4.19-B

12. Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist

c. Prosthetic Devices

(6) Orthotic Appliances and Prosthetic Devices

Reimbursement is based on the lesser of the amount billed or the Title XIX (Medicaid) maximum charge allowed. State developed fee schedule rates are the same for both public and private providers of orthotic appliances and prosthetic devices.

Effective for dates of service occurring on and after September 1, 2006, reimbursement rate maximums for Medicaid covered orthotic appliances and prosthetic devises are based on 100% of the 2006 DMEPOS Medicare rates.

For the following procedure codes not reflecting a rate on the 2006 DMEPOS Medicare fee schedule, reimbursement rate maximums for dates of service occurring September 1, 2006 and after, will be based on 100% of the 2006 Arkansas Blue Cross/Blue Shield rate:

A5510 = $30.28, L0452 = $263.81, L3202 = $51.21, L3204 = $50.12, L3206 = $51.93, L3207 = $52.67, L3208 = $28.58, L3209 = $39.53, L3211 = $42.11, L3215 = $93.94, L3216 = $113.29, L3219 = $105.26, L3221 = $126.00, L3222 = $139.22, L3230 = $163.33, L3250 = $331.47, L3253 = $44.64, L3257 = $32.95, L3265 = $20.54,L3902 = $1,980.19, L4205 = $35.00, L4210 = $28.27, L7500 = $67.55, L7520 = $15.00

Notes

016.06.06 Ark. Code R. 073

10/26/2006