ࡱ> 5 f%!bjbj\\ 9,!>i1g>i1gU?}FFSSTTT2T2T2T8jT ^^c2TJP,%  $VTn2@n2n2SS$aaan2(SRTan2aaS"w0X8BApˮ<U"Zw^շTL!6a ',9+5]n2n2n2n2FX pR: Section ii - Prosthetics Contents TOC \o "1-9" \n \h \z \t "chead1,1,chead2,2"  HYPERLINK \l "_Toc71201969" 200.000 GENERAL INFORMATION  HYPERLINK \l "_Toc71201970" 201.000 Arkansas Medicaid Participation Requirements for Prosthetics Providers  HYPERLINK \l "_Toc71201971" 201.100 Providers in Arkansas and Bordering States  HYPERLINK \l "_Toc71201972" 201.110 Routine Services Provider  HYPERLINK \l "_Toc71201973" 201.200 Providers in Non-Bordering States  HYPERLINK \l "_Toc71201974" 201.210 Limited Services Provider  HYPERLINK \l "_Toc71201975" 202.000 The Prosthetics Provider Role in the Child Health Services (EPSDT) Program  HYPERLINK \l "_Toc71201976" 203.000 Documentation Requirements  HYPERLINK \l "_Toc71201977" 203.100 Documentation in Beneficiarys Case Files  HYPERLINK \l "_Toc71201978" 203.200 Reserved  HYPERLINK \l "_Toc71201979" 203.300 Reserved  HYPERLINK \l "_Toc71201980" 204.000 Electronic Signatures  HYPERLINK \l "_Toc71201981" 210.000 PROGRAM COVERAGE  HYPERLINK \l "_Toc71201982" 211.000 Scope  HYPERLINK \l "_Toc71201983" 211.100 Condition for Provision of Services  HYPERLINK \l "_Toc71201984" 211.200 Physicians Role in the Prosthetics Program  HYPERLINK \l "_Toc71201985" 211.300 Prosthetics Service Provision  HYPERLINK \l "_Toc71201986" 211.400 Prescription and Referral Renewal  HYPERLINK \l "_Toc71201987" 211.500 Service Initiation Delays  HYPERLINK \l "_Toc71201988" 211.600 Termination of Services  HYPERLINK \l "_Toc71201989" 211.700 Exclusions  HYPERLINK \l "_Toc71201990" 211.800 Electronic Filing of Extension of Benefits  HYPERLINK \l "_Toc71201991" 212.000 Services Provided  HYPERLINK \l "_Toc71201992" 212.100 Diapers and Underpads for Individuals Age 3 and Older  HYPERLINK \l "_Toc71201993" 212.200 Durable Medical Equipment (DME), All Ages  HYPERLINK \l "_Toc71201994" 212.201 (DME) Apnea Monitors for Infants Under Age 1  HYPERLINK \l "_Toc71201995" 212.202 (DME) Speech Generating Device (SGD), All Ages  HYPERLINK \l "_Toc71201996" 212.203 Cochlear Implants for Beneficiaries Under Age 21  HYPERLINK \l "_Toc71201997" 212.204 (DME) Electronic Blood Pressure Monitor and Cuff for Beneficiaries of All Ages  HYPERLINK \l "_Toc71201998" 212.205 (DME) Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply Kit for Beneficiaries Under Age 21  HYPERLINK \l "_Toc71201999" 212.206 (DME) Home Blood Glucose Monitor, Pregnant Women Only, All Ages  HYPERLINK \l "_Toc71202000" 212.207 (DME) Insulin Pump and Supplies, All Ages  HYPERLINK \l "_Toc71202001" 212.208 Reserved  HYPERLINK \l "_Toc71202002" 212.209 (DME) Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) and Supplies for Beneficiaries of All Ages  HYPERLINK \l "_Toc71202003" 212.210 DME Low-Profile Percutaneous Cecostomy Tube (Low-Profile Button) for Beneficiaries of All Ages  HYPERLINK \l "_Toc71202004" 212.211 Reserved  HYPERLINK \l "_Toc71202005" 212.212 (DME) Specialized Rehabilitative Equipment, All Ages  HYPERLINK \l "_Toc71202006" 212.213 (DME) Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult  HYPERLINK \l "_Toc71202007" 212.214 Reserved  HYPERLINK \l "_Toc71202008" 212.300 Medical Supplies, All Ages  HYPERLINK \l "_Toc71202009" 212.400 Nutritional Formulae for Individuals Under Age 21  HYPERLINK \l "_Toc71202010" 212.500 Food Thickeners, All Ages  HYPERLINK \l "_Toc71202011" 212.600 Orthotic Appliances and Prosthetic Devices, All Ages  HYPERLINK \l "_Toc71202012" 212.700 Oxygen and Oxygen Supplies, All Ages  HYPERLINK \l "_Toc71202013" 220.000 PRIOR AUTHORIZATION  HYPERLINK \l "_Toc71202014" 221.000 Prosthetics Services Prior Authorization  HYPERLINK \l "_Toc71202015" 221.100 Request for Prior Authorization  HYPERLINK \l "_Toc71202016" 221.200 Filing for Prior Authorization  HYPERLINK \l "_Toc71202017" 221.300 Approvals of Prior Authorization  HYPERLINK \l "_Toc71202018" 221.400 Denial of Prior Authorization Request  HYPERLINK \l "_Toc71202019" 221.500 Reconsideration of Denials  HYPERLINK \l "_Toc71202020" 221.600 Fair Hearing Request  HYPERLINK \l "_Toc71202021" 230.000 REIMBURSEMENT  HYPERLINK \l "_Toc71202022" 231.000 Prosthetics Service Method of Reimbursement  HYPERLINK \l "_Toc71202023" 231.010 Fee Schedule  HYPERLINK \l "_Toc71202024" 232.000 Specialized Wheelchair, Seating and Rehabilitative Equipment Reimbursement for Repairs  HYPERLINK \l "_Toc71202025" 233.000 Orthotic and Prosthetic Reimbursement for Repairs  HYPERLINK \l "_Toc71202026" 234.000 Durable Medical Equipment (DME) Reimbursement for Repairs  HYPERLINK \l "_Toc71202027" 235.000 Speech Generating Device Reimbursement for Repairs  HYPERLINK \l "_Toc71202028" 236.000 Reimbursement for Repair of the Enteral Nutrition Pump  HYPERLINK \l "_Toc71202029" 237.000 Rate Appeal Process  HYPERLINK \l "_Toc71202030" 240.000 billing procedures  HYPERLINK \l "_Toc71202031" 241.000 Introduction to Billing  HYPERLINK \l "_Toc71202032" 242.000 CMS-1500 Billing Procedures  HYPERLINK \l "_Toc71202033" 242.100 HCPCS Procedure Codes  HYPERLINK \l "_Toc71202034" 242.105 Payment Methodology  HYPERLINK \l "_Toc71202035" 242.110 Respiratory and Diabetic Equipment, All Ages  HYPERLINK \l "_Toc71202036" 242.111 Initial Rental of a DME Item for Individuals of All Ages  HYPERLINK \l "_Toc71202037" 242.112 Home Blood Glucose Monitor and Supplies Pregnant Women Only, All Ages  HYPERLINK \l "_Toc71202038" 242.120 Medical Supplies for Beneficiaries of All Ages  HYPERLINK \l "_Toc71202039" 242.121 Food Thickeners, All Ages  HYPERLINK \l "_Toc71202040" 242.122 Jobst Stocking for Beneficiaries of All Ages  HYPERLINK \l "_Toc71202041" 242.123 Negative Pressure Wound Therapy Pump Accessories and Supplies for Beneficiaries Ages 2 Years and Older  HYPERLINK \l "_Toc71202042" 242.130 Diapers and Underpads for Beneficiaries Ages 3 Years and Older  HYPERLINK \l "_Toc71202043" 242.140 Electronic Blood Pressure Monitor and Cuff, All Ages  HYPERLINK \l "_Toc71202044" 242.150 Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries Under Twenty-one (21) Years of Age  HYPERLINK \l "_Toc71202045" 242.151 Pedia-Pop  HYPERLINK \l "_Toc71202046" 242.152 Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply Kit  HYPERLINK \l "_Toc71202047" 242.153 Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) and Low-Profile Percutaneous Cecostomy Tube and Supplies for Beneficiaries of All Ages  HYPERLINK \l "_Toc71202048" 242.154 Nasogastric Tubing for Individuals Under Age 21  HYPERLINK \l "_Toc71202049" 242.155 Billing and Reimbursement Protocol for FM (Frequency Modulation) System and Replacement Cochlear Implant Parts  HYPERLINK \l "_Toc71202050" 242.160 Durable Medical Equipment, All Ages  HYPERLINK \l "_Toc71202051" 242.161 Reserved  HYPERLINK \l "_Toc71202052" 242.170 Apnea Monitors for Beneficiaries Under 1 Year of Age  HYPERLINK \l "_Toc71202053" 242.180 Orthotic Appliances for Beneficiaries of All Ages  HYPERLINK \l "_Toc71202054" 242.190 Prosthetic Devices for Beneficiaries of All Ages  HYPERLINK \l "_Toc71202055" 242.191 Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult  HYPERLINK \l "_Toc71202056" 242.192 Specialized Rehabilitative Equipment for Beneficiaries of All Ages  HYPERLINK \l "_Toc71202057" 242.193 Speech Generating Device for Beneficiaries of All Ages  HYPERLINK \l "_Toc71202058" 242.194 Replacement, Growth and Modification of Specialized Wheelchairs and Wheelchair Seating Systems  HYPERLINK \l "_Toc71202059" 242.195 Repairs of Specialized Wheelchairs and Wheelchair Systems  HYPERLINK \l "_Toc71202060" 242.200 National Place of Service and Modifier Codes  HYPERLINK \l "_Toc71202061" 242.300 Billing Instructions - Paper Only  HYPERLINK \l "_Toc71202062" 242.310 Completion of CMS-1500 Claim Form  HYPERLINK \l "_Toc71202063" 242.400 Special Billing Procedures  HYPERLINK \l "_Toc71202064" 242.401 National Drug Codes (NDCs)  HYPERLINK \l "_Toc71202065" 242.402 Billing of Multi-Use and Single-Use Vials  HYPERLINK \l "_Toc71202066" 242.410 Completion of Form - Medicare/Medicaid Deductible And Coinsurance  HYPERLINK \l "_Toc71202067" 242.420 Freight Charges, All Ages  200.000 GENERAL INFORMATION201.000 Arkansas Medicaid Participation Requirements for Prosthetics Providers11-1-09Prosthetics providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual as well as the following criteria to be eligible to participate in the Arkansas Medicaid Program: Durable Medical Equipment, Prosthetics, Orthotics and Medical Suppliers must be enrolled in the Title XVII (Medicare) Program as a durable medical equipment/oxygen, orthotic appliances or prosthetic device provider. A copy of the verification letter that reflects the providers Medicare supplier number must be submitted with the provider application and Medicaid contract. A separate letter and Medicare supplier number must be submitted for each Medicaid service location. Providers must provide Arkansas Medicaid proof of DME Medicare accreditation and surety bond dated on or after October 1, 2009. New Providers will be required to submit Medicare accreditation and surety bond upon enrollment. NOTE: The orthotics/prosthetics provider should maintain accreditation by the American Board for Certification in Orthotics and Prosthetics. The provider should ensure that staff providing patient care (including but not limited to direct care, evaluations, diagnoses, fabrication fittings and follow up care) are accredited by the American Board for Certification in Orthotics and Prosthetics and meet all national licensing and certification requirements and all licensing and certifications required by the State of Arkansas. 201.100 Providers in Arkansas and Bordering States10-13-03Providers in Arkansas and the six bordering states (Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas) may be enrolled as routine services providers if they meet all Arkansas Medicaid participation requirements outlined above. 201.110 Routine Services Provider12-15-14A. Routine services providers may be enrolled in the program as providers of routine services. B. Reimbursement may be available for durable medical equipment/oxygen, orthotic appliances and prosthetic devices covered in the Arkansas Medicaid Program. C. Claims must be filed according to the specifications in this manual. This includes assignment of ICD and HCPCS codes for all services rendered. 201.200 Providers in Non-Bordering States3-1-11Providers in non-bordering states may enroll only as limited services providers. 201.210 Limited Services Provider3-1-11A. Limited services providers may enroll in the Arkansas Medicaid program to provide prior authorized or emergency services only. B. Emergency services are defined as inpatient or outpatient hospital services that a prudent layperson with an average knowledge of health and medicine would reasonably believe are necessary to prevent death or serious impairment of health and which, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services. Source: 42 U.S. Code of Federal Regulations 422.2 and 424.101. C. Prior authorized services are those that are medically necessary and not available in Arkansas. Each request for these services must be made in writing, forwarded to the Division of Medical Services, Utilization Review Section and approved before the service is provided. See Section 220.000 of this manual for instructions for obtaining prior authorization. To enroll, a non-bordering state provider must download an Arkansas Medicaid application and contract from the Arkansas Medicaid website and submit the application, contract and claim to Arkansas Medicaid Provider Enrollment. A provider number will be assigned upon receipt and approval of the provider application and Medicaid contract. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMSUR.doc"View or print the Utilization Review Section contact information. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/ApplicationPacket.doc"View or print the provider enrollment and contract package (Application Packet). HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/ProviderEnrol.doc"View or print Medicaid Provider Enrollment Unit contact information. D. Limited services provider claims will be manually reviewed prior to processing to ensure that only emergency or prior authorized services are approved for payment. These claims should be mailed to the Arkansas Division of Medical Services Program Communications Unit. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMSProgramCom.doc"View or print the Arkansas Division of Medical Services Program Communications Unit contact information. Providers such as pharmacies, home health agencies or hospitals which have agreements with Medicaid to provide services to Medicaid beneficiaries must complete a separate Medicaid contract and provider application to provide durable medical equipment/oxygen, orthotic appliances and prosthetic devices. A separate provider number will be assigned. 202.000 The Prosthetics Provider Role in the Child Health Services (EPSDT) Program10-13-03The Child Health Services (EPSDT) program is a federally mandated child health component of Medicaid. It is designed to bring comprehensive health care to individuals eligible for medical assistance from birth up to their 21st birthday. The purpose of this program is to detect and treat health problems in the early stages and to provide preventive health care, including necessary immunizations. Child Health Services (EPSDT) combines case management and support services with screening, diagnostic and treatment services delivered on a periodic basis. If a condition is diagnosed through a Child Health Services (EPSDT) screen that requires treatment services not normally covered under the Arkansas Medicaid Program, those treatment services will also be considered for reimbursement if the service is medically necessary and permitted under federal Medicaid regulations. Prosthetics providers who are Child Health Services (EPSDT) providers are encouraged to refer to the Child Heath Services (EPSDT) provider manual for additional information. 203.000 Documentation Requirements11-1-09Prosthetics providers must keep and properly maintain written records. Along with the required enrollment documentation, which is located in Section 141.000, the following records must be included in the beneficiarys case file maintained by the provider. 203.100 Documentation in Beneficiarys Case Files9-1-18The provider must develop and maintain sufficient written documentation to support each service for which billing is made. All entries in a beneficiarys file must be signed and dated by the individual who provided the service, along with the individuals title. The documentation must be kept in the beneficiarys case file. Documentation should consist of, at a minimum, material that includes: A. An audit trail between the prosthetics provider, the beneficiary, the beneficiarys primary care physician and advanced practice registered nurse and the Division of Medical Services. B. When applicable, documentation including the request for and approval of prior authorization and/or the request for and approval of extension of benefits for services provided. C. Prescriptions for prosthetics services, signed and dated by the beneficiarys primary care physician or advanced practice registered nurse within the scope of practice. D. The prosthetics providers signed and dated: 1. Certification that used equipment is reconditioned, is in good working order and has no defects in workmanship or material 2. The beneficiarys consent to receive services 3. Notification of termination of prosthetics services 4. Documentation to reflect that necessary training and orientation has been provided to the beneficiary and any other applicable persons 5. Any additional or special documentation, requested in writing, that is needed to provide fair and impartial review of individual cases, requested in writing. 203.200 Reserved11-1-09203.300 Reserved11-1-09204.000 Electronic Signatures10-8-10Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code 25-31-103 et seq. 210.000 PROGRAM COVERAGE211.000 Scope1-1-21There are several broad areas of service provision in the Prosthetics manual. Services provided include durable medical equipment, which also encompasses specialized wheelchairs, wheelchair seating systems, specialized rehabilitation equipment and the speech generating device. Other programs covered in the Prosthetics manual include medical supplies, nutritional formulas, diapers and underpads, prosthetic devices and orthotic appliances. 211.100 Condition for Provision of Services9-1-18The following conditions must be met for the provision of services: A. The beneficiary must reside in the state of Arkansas. B. The individual must be an Arkansas Medicaid beneficiary. C. Services must be medically necessary and prescribed by the beneficiarys primary care physician (PCP) or Advanced Practice Registered Nurses (APRN) unless the beneficiary is exempt from PCP requirements. A PCP referral is required. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/Section_I.doc"See Section I. D. A beneficiary is accepted for services on the basis of a reasonable expectation that his or her medical needs can be adequately met by the provider. E. When applicable, Form DMS-679, titled Medical Equipment Request for Prior Authorization and Prescription, must be utilized when requesting prior authorization for wheelchairs, wheelchair seating systems, wheelchair repairs, for eligible Medicaid beneficiaries. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679.doc"View or print form DMS-679 and instructions for completion. F. When applicable, form DMS-679A, titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be utilized when requesting prior authorization for some medical supplies (i.e.: compression burn garments), orthotics appliances, prosthetic devices and durable medical equipment, excluding wheelchairs, wheelchair seating systems or wheelchair repairs, when these items are prescribed for eligible Medicaid beneficiaries. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. G. When applicable, form DMS-602, titled Request for Extension of Benefits for Medical Supplies for Medicaid Beneficiaries Under Age 21, must be utilized when requesting extension of benefits for medical supplies for beneficiaries under age 21. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-602.doc"View or print form DMS-602 and instructions for completion. H. When applicable, form DMS-699, titled Request for Extension of Benefits, must be utilized when requesting extension of benefits for diapers and underpads for eligible beneficiaries ages three and older. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-699.doc"View or print form DMS-699. I. The beneficiary must reside in his or her own dwelling, an apartment, relatives or friends home, boarding home, residential care facility or any other type of supervised living situation that is not required to provide prosthetics services as part of the facilitys participation agreement as a service provider. A beneficiarys place of residence for services may not include a hospital, skilled nursing facility, intermediate care facility or any other supervised living situation that is required to provide prosthetics services under a provider agreement or contract as required by federal, state or local regulation. 211.200 Physicians Role in the Prosthetics Program9-1-18At least once every 6 months, the primary care physician or advanced practice registered nurse within the scope of practice must certify the medical necessity for services and prescribe them by signing and dating a prescription. When applicable, the primary care physician or advanced practice registered nurse within the scope of practice must complete a prior authorization form; either a Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) when prescribing services for wheelchairs and wheelchair seating systems, or wheelchair repairs or a form DMS-679A, titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, when prescribing orthotic appliances, prosthetic devices or durable medical equipment. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679.doc"View or print form DMS-679 and instructions for completion. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. 211.300 Prosthetics Service Provision9-1-18At least once every 6 months, the prosthetics provider must receive a prescription for prosthetics services from either the beneficiarys primary care physician or advanced practice registered nurse within the scope of practice and, when applicable: A. Prepare a Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) for wheelchairs, wheelchair seating systems or wheelchair repairs for beneficiaries 21 years of age or older and for specified services for beneficiaries under age 21. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679.doc"View or print form DMS-679 and instructions for completion. B. Prepare a Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components for some medical supplies (i.e.: compression burn garments), orthotic appliances, prosthetic devices and durable medical equipment for beneficiaries 21 years of age or older and for specified services for beneficiaries under age 21. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. C. Send the prepared request for prior authorization to either the beneficiarys primary care physician or advanced practice registered nurse within the scope of practice for prescriptions D. Send the completed Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) to the Arkansas Foundation for Medical Care for prior authorization. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print the AFMC contact information. E. Send the Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to the Arkansas Foundation for Medical Care, Inc. (AFMC) for prior authorization. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print the AFMC contact information. As necessary, the provider must: A. Deliver and set up the prescribed equipment in the beneficiarys home, B. Teach the beneficiary, families and caregivers the correct use and maintenance of equipment, C. Repair equipment within 3 working days of notification, D. Retrieve from the beneficiarys home equipment no longer prescribed for the beneficiary and E. Provide necessary documentation. 211.400 Prescription and Referral Renewal9-1-18At least once every 6 months, but within 30 working days before the end of currently prescribed or prior authorized prosthetics services, the prosthetics provider must obtain a new prescription from either the beneficiarys primary care physician or advanced practice registered nurse within the scope of practice and, if applicable, send a new prior authorization form to the applicable entity. The primary care physician or advanced practice registered nurse within the scope of practice must initially review either form DMS-679 or form DMS-679A, and, based upon the physicians certification of medical necessity, prescribe services. Form DMS-679 or form DMS-679A must then be reviewed by the applicable entity and services must be prior authorized. If services are prescribed, and when applicable, prior authorized, services may be furnished for a maximum of 6 months from the date of the prescription. 211.500 Service Initiation Delays9-1-18If all prescribed prosthetics services are not begun by the prosthetics provider within 30 working days of the prescription date, the prosthetics provider must notify the beneficiary and either the beneficiarys primary care physician or advanced practice registered nurse within the scope of practice in writing and explain the delay. The provider must retain documentation justifying the service delay. 211.600 Termination of Services9-1-18If prosthetics services are terminated, the provider must notify either the beneficiarys primary care physician or advanced practice registered nurse within the scope of practice and the beneficiary (if not deceased) in writing, within 10 working days of the termination, documenting the effective date of and reasons for the termination. 211.700 Exclusions8-1-05Services that are not covered under the Arkansas Medicaid Prosthetics Program include but are not limited to: A. Over-the-counter items provided through the Arkansas Medicaid Pharmacy Program (except as specified). B. Over-the-counter drugs (except as specified). C. Products that bear the Federal legend Caution: Federal Law Prohibits Dispensing Without A Prescription (except as specified). D. Specialized wheelchair equipment that has been previously purchased by any payer. Specialized wheelchair equipment may not be reordered unless the patients condition changes and necessitates a change in prescription. This change in condition must be thoroughly documented. E. Wheelchairs for individuals under 21 years of age within two years of the purchase of a specialized wheelchair. F. Wheelchairs for individuals age 21 and over within five years of the purchase or rental of a wheelchair. G. Foodstuffs. H. Hyperalimentation. I. Services that duplicate any other service provided to the patient or that replace existing patient supports. 211.800 Electronic Filing of Extension of Benefits1-1-21Form DMS-699, titled Request for Extension of Benefits, serves as both a request form and a notification of approval or denial of extension of benefits when requesting diapers and underpads for beneficiaries age 3 and older. If the benefit extension is approved, the form returned to the provider will contain a Benefit Extension Control Number. The approval notification will also list the procedure codes approved for benefit extension, the approved dates or date-of-service range and the number of units of service (or dollars, when applicable) authorized. Upon notification of a benefit extension approval, providers may file the benefit extension claims electronically, entering the assigned Benefit Extension Control Number in the Prior Authorization (PA) number field. Subsequent benefit extension requests to the Utilization Review Section will be necessary only when the Benefit Extension Control Number expires or when a beneficiarys need for services unexpectedly exceeds the amount or number of services granted under the benefit extension. Form DMS-679A, titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components serves as a request form when requesting extension of benefits for the speech generating device. The QIO will notify providers of approval or denial by letter. 212.000 Services Provided212.100 Diapers and Underpads for Individuals Age 3 and Older6-1-09Diapers and underpads are covered by the Arkansas Medicaid Program but are benefit limited and must be medically necessary. A. Medical Necessity Diaper services must be medically necessary and the medical condition that prohibits the ability to potty train must be documented. Only patients with a medical condition that results in incontinence of the bladder and/or bowel may receive diapers through the Home Health and Prosthetics Programs. This coverage does not apply to infants who would be in diapers regardless of their medical condition. Medicaid does not cover underpads or diapers for beneficiaries under the age of 3 years. B. Benefit Limit The benefit limit for diapers and underpads is $130.00 per month, per beneficiary, for diapers of any size and underpads. The benefit limit applies to any diaper or underpad, or any combination, whether provided through the Prosthetics Program, the Home Health Program or both. The limit on diapers and underpads is separate from the limit established for home health and durable medical equipment (DME) medical supplies. The benefit may be extended with proper documentation. C. Extension of Benefits for Diapers and Underpads To obtain an extension of benefits for diapers and underpads, the following information must be submitted to the Prosthetics Services Reviewer, DMS Utilization Review. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMSUR.doc"View or print the DMS Utilization Review contact information. 1. A completed Medicaid Form DMS-699, titled Request for Extension of Benefits for the requested time period prior to the delivery of the product. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-699.doc"View or print form DMS-699. 2. Documentation supported by the medical record substantiating the medical necessity of an extension of benefits, including the prescription(s) for all prescribed incontinence products. 212.200 Durable Medical Equipment (DME), All Ages8-1-05Durable medical equipment (DME) is equipment that can withstand repeated use and is used to serve a medical purpose. Depending on the item involved, DME may be purchased for or by a beneficiary or may be rented. The equipment may be new or, in special circumstances, used equipment. 212.201 (DME) Apnea Monitors for Infants Under Age 13-1-10Arkansas Medicaid covers apnea monitors only for infants less than one (1) year of age. Use of the apnea monitor must be medically necessary and prescribed by a physician. A primary care physician (PCP) is not required until an infant's Medicaid eligibility has been determined. No PCP referral for medical services is required for retroactive eligibility periods. For the initial certification, the prescribing physician must sign form DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. The physicians signature must be an original, not a stamp. When an apnea monitor is prescribed during a hospital discharge, the physician ordering the apnea monitor must be in consultation with a neonatologist or pulmonologist. As necessary, the primary care physician's (PCPs) name and provider number must also be indicated on DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. The PCP's signature is not required on the initial certification but he or she must sign all re-certifications. A prior authorization request for an apnea monitor must be submitted to AFMC on form DMS-679A titled Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679.doc"View or print form DMS-679 and instructions for completion. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print AFMC contact information. Compliance, and the download monitor report, must accompany the request for continued use of the apnea monitor following the initial sixty-day time period. Prior authorization is not required for the initial sixty-day period of use of the monitor. If the apnea monitor is needed longer than an initial sixty-day period, prior authorization is required. A new prescription, documentation of compliance during the initial sixty-day period and proof of medical necessity for the continuation of monitoring are required. The following criteria, established by the American Academy of Pediatrics, are to be used to evaluate the need for an apnea monitor after the initial sixty-day period: A. Evidence exists that preterm infants are at greater risk of extreme apnea episodes until approximately 43 weeks post conceptual age. Monitoring may be indicated until 43 weeks post conceptual age unless extreme episodes persist beyond that time. Home monitoring may be indicated for other selected groups of infants, as well. B. Home cardiorespiratory monitoring may be warranted for premature infants who are at high risk of recurrent episodes of apnea, bradycardia, and hypoxemia after hospital discharge. The use of home cardiorespiratory monitoring in this population should be limited to approximately 43 weeks post conceptual age or after the cessation of extreme episodes, whichever comes last. C. Home cardiorespiratory monitoring may be warranted for infants who are technology dependent (tracheostomy, supplemental oxygen, continuous positive airway pressure, etc.), have unstable airways, have rare medical conditions affecting regulation of breathing or have symptomatic chronic lung disease. In many of these cases, the use of pulse oximetry monitoring is superior and preferred over simple cardiorespiratory monitoring. D. Other infants who may benefit from home cardiorespiratory home monitoring include: 1. Infants who have experienced an apparent life-threatening event (ALTE) An ALTE is defined as an episode that is frightening to the observer and is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking or gagging. 2. Infants with tracheotomies or anatomic abnormalities that may compromise their airway 3. Infants with metabolic or neurological abnormalities affecting respiratory control 4. Infants with chronic lung disease of prematurity (bronchopulmonary dysplasia, BPD), especially those requiring some form of respiratory support E. Parents or caregivers must be counseled regarding the purpose of the home cardiorespiratory monitoring and realistic expectations of what it can and cannot contribute to an infants well being. 1. When monitoring is used in the home, parents and other caregivers must be trained in observation techniques, operation of the monitor, and infant cardiopulmonary resuscitation prior to the use of the monitor. 2. Medical and technical support staff should always be available for direct or telephone consultation. F. Duration and discontinuation of home cardiorespiratory monitoring 1. When home monitoring is prescribed for apnea/bradycardia in preterm infants, the physician should establish a plan for review of clinical and event (download) data at 43 weeks post conceptual age. If monitoring is to be continued beyond that time, documentation should be provided as to why it should be continued as well as a plan for reevaluation. 2. Infants whose mothers have unsure dates (uncertain post-conceptual age) may be monitored until the infants are at least 43 weeks post conceptual age. 3. When home monitoring is prescribed for indications other than apnea/bradycardia in preterm infants, continuation of monitoring will be reviewed on a case-by-case basis. 4. Discontinuation of home monitoring should be a clinical decision based on a combination of clinical data and cardiorespiratory monitor event data. 5. Decisions regarding discontinuation of home monitoring should NOT be based on single-night pneumograms, which have no proven predictive value in this setting. 212.202 (DME) Speech Generating Device (SGD), All Ages1-1-21The speech generating device (SGD) is covered for beneficiaries of all ages. Coverage for beneficiaries under 21 years of age must result from an EPSDT screen. There is a $7,500.00 lifetime benefit for speech generating devices. When a beneficiary who is under age 21 has met the lifetime benefit and it is determined that additional equipment is medically necessary, the provider may request an extension of benefits by submitting form DMS-679A. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A. The SGD is also covered for Medicaid beneficiaries 21 years old and older. Prior authorization is required on the device and on repairs of the device. For beneficiaries who are age 21 and above, there is a $7,500.00 lifetime benefit without benefit extensions. The Arkansas Medicaid Program will not cover SGDs that are prescribed solely for social or educational development. Training in the use of the device is not included and is not a covered cost. Prior authorization must be requested for repairs of equipment or associated items after the expiration of the initial maintenance agreement. The following information must be submitted when requesting prior authorization for SGDs for Medicaid beneficiaries. Submit form DMS-679A, titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. The form should be accompanied by: A. A current speech generating device evaluation completed by a multidisciplinary team consisting of, at least, a speech/language pathologist and an occupational therapist. The team may consist of a physical therapist, regular and special educators, caregivers and parents. The speech-language pathologist must lead the team and sign the SGD evaluation report. (For the qualifications of the team members, see the Hospital/Critical Access Hospital/End Stage Renal Disease provider manual.) 1. The team must use an interdisciplinary approach in the evaluation, incorporating the goals, objectives, skills and knowledge of various disciplines. The team must use at least three SGD systems, with written documentation of each usage included in the SGD assessment. 2. The evaluation report must indicate the medical reason for the SGD. The report must give specific recommendations of the system and justification of why one system is more appropriate than another system. 3. The evaluation report must be submitted to the prosthetics provider who will request prior authorization for the SGD. B. Written denial from the insurance company if the individual has other insurance. This information must be submitted to the QIO. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print QIO contact information. Benefit Limit There is a $7500 lifetime benefit for speech generating devices. When the beneficiary under age 21 has met the limit and it is determined that additional equipment is necessary, the provider may request an extension of benefits. In order to obtain an extension of the $7,500.00 lifetime benefit for beneficiaries under 21 years of age, a medical necessity determination for additional equipment is required. The provider must submit a form DMS-679A, a completed Medicaid claim and medical records substantiating medical necessity that the beneficiary cannot function using his or her existing equipment and whether the equipment can be repaired or needs repair. The information must be sent to the QIO. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print the QIO contact information. The provider will be notified in writing of the approval or denial of the request for extended benefits. 212.203 Cochlear Implants for Beneficiaries Under Age 214-15-11Cochlear implants are covered through the Arkansas Medicaid Physician or Prosthetics Programs for eligible Medicaid beneficiaries under the age of 21 years through the Child Health Services (EPSDT) program when prescribed by a physician. The replacements of lost, stolen or damaged external components (not covered under the manufacturers warranty) are covered when prior authorized by Arkansas Medicaid. Reimbursements for manufacturers upgrades will not be made. An upgrade of a speech processor to achieve aesthetic improvement, such as smaller profile components, or a switch from a body-worn, external sound processor to a behind-the-ear (BTE) model or technological advances in hardware are not considered medically necessary and will not be approved. A. Speech Processor Arkansas Medicaid will not cover new generation speech processors if the existing one is still functional. Consideration of the replacement of the external speech processors will be made only in the following instances: The beneficiary loses the speech processor. The speech processor is stolen. The speech processor is irreparably damaged. Additional medical documentation supporting medical necessity for replacement of external components should be attached to any requests for prior authorization. B. Personal FM (Frequency Modulation) Systems Arkansas Medicaid will reimburse for a personal FM system for use by a cochlear implant beneficiary when prior authorized and not available from any other source (i.e., educational services). The federal Individuals with Disabilities Education Act (IDEA) requires public school systems to provide FM systems for educational purposes for students starting at age three (3). Arkansas Medicaid does not cover FM systems for children who are eligible for this service through IDEA. A request for prior authorization may be submitted for medically necessary FM systems (procedure code V5273 for use with cochlear implant) that are not covered through IDEA; each request must be submitted with documentation of medical necessity. These requests will be reviewed on an individual basis. C. Replacement, Repair, Supplies The repair or replacement of the cochlear implant external speech processor and other supplies (including batteries, cords, battery charger and headsets) will be covered in accordance with the Arkansas Medicaid policy for the Physician and Prosthetics Programs. The covered services must be billed by an Arkansas Medicaid Physician or Prosthetics provider. The supplier is required to request prior authorization for repairs or replacements of external implant parts. D. Prior Authorization A request for prior authorization of a medically necessary FM system (V5273 for use with cochlear implant) and replacement cochlear implant parts requires a paper submission to the Arkansas Foundation for Medical Care (AFMC) using form DMS-679A. All documentation supporting medical necessity should be attached to the form. The provider will be notified in writing of the approval or denial of the request for prior authorization. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. Prior authorization does not guarantee payment for services or the amount of payment for services. Eligibility for, and payment of, services are subject to all terms, conditions and limitations of the Arkansas Medicaid Program. Documentation must support medical necessity. The provider must retain all documentation supporting medical necessity in the beneficiarys medical record. The following procedure codes must be prior authorized. Providers should use the following procedure codes when requesting prior authorization for replacement parts for cochlear implant devices. Applicable manufacturer warranty options must be exhausted before coverage is considered. Most warranties include one replacement for a stolen, lost or damaged piece of equipment free-of-charge by the manufacturer. The table below contains new and existing HCPCS procedure codes for FM systems for use with cochlear implant and replacement cochlear implant parts. NOTE: Coverage and billing requirements for the physician provider for cochlear device implantation are unchanged. Procedure CodeM1Age RestrictionPAPayment MethodL8627*EP0-20YManually PricedL8628*EP0-20YManually PricedL8629*EP0-20YManually Priced *Denotes paper claim See Section 242.155 for information on billing and reimbursement for FM system and replacement cochlear implant parts. 212.204 (DME) Electronic Blood Pressure Monitor and Cuff for Beneficiaries of All Ages4-1-09Arkansas Medicaid covers the automatic electronic blood pressure monitor for beneficiaries of all ages as a rental-only item. A provider must substantiate that an accurate blood pressure reading cannot be obtained by using a regular blood pressure monitor. Providers must also supply one disposable blood pressure cuff each month. Prior authorization is required for the use of this item. Providers may request prior authorization by submitting form DMS-679A, Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print AFMC contact information. 212.205 (DME) Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply Kit for Beneficiaries Under Age 214-1-09The request for an enteral nutrition pump is covered on a case-by-case basis for beneficiaries under age 21 who require supplemental feeding because of medical necessity. Sufficient medical documentation must be provided to establish that the enteral nutrition infusion pump is medically necessary (e.g., supplemental feeding must be given over an extended period of time due to reflux, cystic fibrosis, etc.). The PCP or appropriate physician specialist must prescribe the pump, citing the medical reason that bolus feeds are inappropriate. Reimbursement for use in the home may be made for the pump supply kit when the feeding method involves an enteral nutrition infusion pump. The pump supply kit and the infusion pump require prior authorization from AFMC using form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print AFMC contact information. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. The enteral feeding pump supply kit, necessary for the administration of the nutrients when the feeding method involves an enteral nutrition infusion pump, is reimbursed on a per-unit basis with 1 day equaling 1 unit of service. A maximum of 1 unit per day is allowed. The pump supply kit includes pump sets, containers and syringes necessary for administration of the nutrients. Reimbursement for the enteral nutrition infusion pump is based on a rent-to-purchase methodology. Each unit reimbursed by Medicaid will apply towards the purchase price established by Medicaid. Reimbursement will only be approved for new equipment. Used equipment will not be prior authorized. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. Requests for prior authorization for enteral pump repairs must be mailed to AFMC. Form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be used to request prior authorization. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. 212.206 (DME) Home Blood Glucose Monitor, Pregnant Women Only, All Ages8-1-05Arkansas Medicaid covers the home blood glucose monitor for pregnant women of all ages. Prior authorization is not required for use of this device. A. Patient Eligibility 1. Pregestational diabetes. Women on an oral hypoglycemic or insulin when the pregnancy is diagnosed. 2. Women that are being followed by a physician for elevated fasting hyperglycemia, but not on an oral hypoglycemic or insulin when the pregnancy is diagnosed. 3. Women demonstrating glucose intolerance during the pregnancy as demonstrated by an elevated three-hour glucose tolerance test. B. Criteria for glucose intolerance 1. Demonstration of an elevated one-hour glucose tolerance test of greater than 140 mg/deciliter on a non-fasting value. 2. Elevation of two or more values on a three-hour glucose tolerance test above the accepted cut-off points of: a. Fasting, less than 105 b. One-hour, less than 190 c. Two-hour, less than 165 d. Three-hour, less than 145 212.207 (DME) Insulin Pump and Supplies, All Ages4-1-09Insulin pumps and supplies are covered by Arkansas Medicaid for beneficiaries of all ages. Prior authorization is required for the insulin pump. A prescription and proof of medical necessity are required. The patient must be educated on the use of the pump, but the education is not a covered service. Insulin is also not covered because it is covered in the prescription drug program. The following criteria will be utilized in evaluating the need for the insulin pump: A. Insulin-dependent diabetes that is difficult to control. B. Fluctuation in blood sugars causing both high and low blood sugars in a patient on at least 3, if not 4, injections per day. C. Beneficiarys motivation level in controlling diabetes and willingness to do frequent blood glucose monitoring. D. Beneficiarys ability to learn how to use the pump effectively. This will have to be evaluated and documented by a professional with experience in the use of the pump. E. Determination of the beneficiarys suitability to use the pump should be made by a diabetes specialist or endocrinologist. F. Beneficiaries not included in one of these categories will be considered on an individual basis. Prior authorization requests for the insulin pump and supplies must be submitted on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, to AFMC. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print AFMC contact information. 212.208 Reserved8-1-05212.209 (DME) Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) and Supplies for Beneficiaries of All Ages12-1-20The Arkansas Medicaid Program reimburses for the Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) and supplies for Medicaid-eligible beneficiaries of all ages. Prior authorization (PA) from DHS or its designated vendor is required. When requesting prior authorization, form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be completed and sent, along with sufficient medical documentation. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print contact information for how to submit the request. The Low-Profile Kit is benefit-limited to two (2) per state fiscal year (SFY). The accessories, extension sets, and adapters are covered under the $250 medical supply benefit limit. Benefit extensions will be considered on a case-by-case basis if proven to be medically necessary. 212.210 DME Low-Profile Percutaneous Cecostomy Tube (Low-Profile Button) for Beneficiaries of All Ages12-1-20The Low-Profile Button for a Percutaneous Cecostomy Tube requires use of the following diagnosis codes. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/PROSTHET_212.210.xls"(View ICD codes.) The Low-Profile Button for a Percutaneous Cecostomy Tube requires use of the following CPT codes: 443004944249450 212.211 Reserved8-1-05212.212 (DME) Specialized Rehabilitative Equipment, All Ages4-1-09Arkansas Medicaid covers specialized rehabilitative equipment for Medicaid-eligible beneficiaries of all ages. Some items of specialized equipment require prior authorization from AFMC. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print AFMC contact information. 212.213 (DME) Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult4-6-15Arkansas Medicaid covers specialized wheelchairs and wheelchair seating systems for individuals age two through adulthood. Some items of specialized equipment require prior authorization from the Arkansas Foundation for Medical Care (AFMC). HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679.doc"View or print form DMS-679 and instructions for completion. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print the AFMC contact information. 212.214 Reserved8-1-05212.300 Medical Supplies, All Ages7-1-17The Arkansas Medicaid Program reimburses home health providers and prosthetics providers for covered medical supplies up to a maximum of $250.00 per month, per beneficiary. The $250.00 may be provided by the Home Health program, the Prosthetics program or a combination of the two. A beneficiary may not receive more than a total of $250.00 of supplies per month unless an extension has been granted. Extensions will be considered for beneficiaries under age 21 in the Child Health Services (EPSDT) program if documentation verifies medical necessity. A provider must request an extension of the benefit limit for a Medicaid beneficiary under age 21 by completing the Request for Extension of Benefits for Medical Supplies for Medicaid Recipients Under Age 21 (form DMS-602.) HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-602.doc"View or print form DMS-602 and instructions for completion. The Arkansas Medicaid program covers medical supplies using a specific HCPCS procedure code for each specific item. Only supply items that are listed and have a corresponding payable HCPCS procedure code are covered. Supplies are healthcare-related items that are consumable or disposable, or cannot withstand repeated use by more than one individual, and that are required to address an individual medical disability, illness or injury. Equipment and appliances are items that are primarily and customarily used to serve a medical purpose; generally are not useful to an individual in the absence of a disability, illness or injury; can withstand repeated use; and can be reusable or removable. Medical coverage of equipment and appliances is not restricted to items covered as durable medical equipment in the Medicare program. Arkansas has a list of preapproved medical equipment, supplies and appliances for administrative ease, but the state is prohibited from having absolute exclusions of coverage on medical equipment, supplies or appliances. Items not available on the preapproval list may be requested on a case-by-case basis. When denying a request, the state must inform the beneficiary of the right to a fair hearing. 212.400 Nutritional Formulae for Individuals Under Age 218-1-05Nutritional formulae may be covered by the Arkansas Medicaid Program when prescribed by a physician and documented as medically necessary for beneficiaries under age 21 participating in the Child Health Services (EPSDT) Program. The Women, Infants and Children Program (WIC) must be accessed first for individuals who are age 0 through age 5. Nutritional formula may not be billed for the same beneficiary by more than one provider or in more than one program (e.g., Prosthetics and Hyperalimentation) for the same date of service. Covered formulae represent the nutritional supplements most requested for medical purposes. However, if none of the formulae are appropriate and another formula is prescribed by a physician as a result of Child Health Services (EPSDT) screening, the prescribed formula will be reviewed for medical necessity. Formulae are covered as nutritional supplements rather than as the sole source of nutrition. Beneficiaries who require enteral nutrition as the sole source of nutrition, with the formulae being administered through a nasogastric, jejunostomy or gastrostomy tube, should be referred to a hyperalimentation provider enrolled in the Medicaid Program. One unit of service equals 100 calories with an allowable maximum of 30 units per day. This is a separate benefit limit from the limit established for medical supplies. Supplies provided in conjunction with the nutritional formulae through the Prosthetics Program must be billed under the medical supply codes, if those supplies are covered by the program. There are certain nutritional formulae available to eligible beneficiaries through the WIC Program and the Food Stamp Program. These two programs should be accessed by beneficiaries prior to requesting Medicaid reimbursement for nutritional formulae. The coverage of these formulae through the Medicaid Program is limited to beneficiaries requiring nutrition therapy due to medical necessity and only when prescribed by a physician. 212.500 Food Thickeners, All Ages8-1-05Arkansas Medicaid covers food thickeners for Medicaid-eligible individuals who have impaired swallowing and a risk of food aspiration. Food thickeners are not subject to the $250 benefit limit for other medical supplies. 212.600 Orthotic Appliances and Prosthetic Devices, All Ages5-22-19A. The Arkansas Medicaid Program covers orthotic appliances and prosthetic devices for beneficiaries under age 21 in the Child Health Services (EPSDT) Program. Providers of orthotic appliances and prosthetic devices may be reimbursed by the Arkansas Medicaid Program when the items are prescribed by a physician and documented as medically necessary for beneficiaries under age 21 participating in the Child Health Services (EPSDT) Program. 1. No prior authorization is required to obtain these services for beneficiaries under age21. 2. No benefit limits apply to orthotic appliances and prosthetic devices for beneficiaries under age 21. B. Arkansas Medicaid covers orthotic appliances for beneficiaries age 21 and over. The following provisions must be met before services may be provided. 1. Prior authorization is required for orthotic appliances valued at or above the Medicaid maximum allowable reimbursement rate of $500.00 per item for use by beneficiaries age 21 and over. Prior authorization may be requested by submitting form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print AFMC contact information. 2. For beneficiaries age 21 and over, a benefit limit of $3,000 per state fiscal year (SFY; July 1 through June 30) has been established for reimbursement for orthotic appliances. No extension of benefits will be granted. The following restrictions apply to the coverage of orthotic appliances for beneficiaries age 21 and over: a. Orthotic appliances may not be replaced for 12 months from the date of purchase. If a beneficiarys condition warrants a modification or replacement and the $3,000.00 SFY benefit limit has not been met, the provider may submit documentation to AFMC, to substantiate medical necessity. If approved, AFMC will issue a prior authorization number. Section 221.000 of this provider manual may be referenced for information regarding prior authorization procedures. b. Custom-molded orthotic appliances are not covered for a diagnosis of carpal tunnel syndrome prior to surgery. C. Arkansas Medicaid covers prosthetic devices for beneficiaries age 21 and over; however, the following provisions must be met before services may be provided. 1. Prior authorization will be required for prosthetic device items valued at or in excess of the $1,000.00 per item Medicaid maximum allowable reimbursement rate for use by beneficiaries age 21 and over. Prior authorization may be requested by submitting form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. 2. For beneficiaries age 21 and over, a benefit limit of $60,000 per SFY has been established for reimbursement for prosthetic devices. No extension of benefits will be granted. 3. The following restrictions apply to coverage of prosthetic devices for beneficiaries age 21 and over: a. Prosthetic devices may be replaced only after five years have elapsed from their date of purchase. If the beneficiarys condition warrants a modification or replacement, and the $60,000 per SFY benefit limit has not been met, the provider may submit documentation to AFMC to substantiate medical necessity. If approved, AFMC will issue a prior authorization number. Section 220.000 of this provider manual may be referenced for information regarding prior authorization procedures. b. Myoelectric prosthetic devices may be purchased only when needed to replace myoelectric devices received by beneficiaries who were under age 21 when they received the original device. D. The forms, listed below, are available for evaluating the need of beneficiaries age 21 and over for orthotic appliances and prosthetic devices, and prescribing the needed appliances and equipment. The Medicaid Program does not require providers to use the forms, but the information the forms are designed to collect is required by Medicaid to process requests for prior authorization of orthotic appliances and prosthetic devices for beneficiaries aged 21 and over. The appropriate forms (or the required information in a different format) must accompany the form DMS-679A. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components and instructions for completion. The forms and their titles are as follows: 1. DMS-647 Gait Analysis: Full Body. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-647.doc"View or print form DMS-647. 2. DMS-648 Upper-Limb Prosthetic Evaluation. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-648.doc"View or print form DMS-648. 3. DMS-649 Upper-Limb Prosthetic Prescription. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-649.doc"View or print form DMS-649. 4. DMS-650 Lower-Limb Prosthetic Evaluation. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-650.doc"View or print form DMS-650. 5. DMS-651 Lower-Limb Prosthetic Prescription. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-651.doc"View or print form DMS-651. 212.700 Oxygen and Oxygen Supplies, All Ages4-1-09A prescription for oxygen must be accompanied by a current arterial blood gas (ABG) laboratory report from a certified laboratory or the beneficiarys attending physician. A current laboratory report is defined as one performed within a maximum of 30 days prior to the prescription for oxygen. A prescription for oxygen must specify the oxygen flow rate, frequency and duration of use, estimate of the period of need for oxygen and method of delivery of oxygen to the beneficiary (e.g., two liters per minute, 10 minutes per hour, by nasal cannula for a period of two months). A prescription containing only oxygen PRN is not sufficient. The following medical criteria will be utilized in evaluating coverage of oxygen: A. Chronic Respiratory Disease 1. Continuous oxygen therapy Resting Pa02 less than 55 mm Hg 2. Nocturnal oxygen therapy Resting Pa02 less than 60 mm Hg 3. Exercise oxygen therapy Pa02 with exercise less than 55 mm Hg B. Congestive Heart Failure Symptomatic at rest, with Pa02 less than 60 mm Hg C. Carcinoma of the Lung Resting Pa02 less than 60 mm Hg D. Others Reviewed on an individual basis E. Children O2 saturation below 94% by pulse oximeter with elevated PCO2 by capillary blood gas or end-tidal CO2 on two separate occasions. The prior authorization request for all oxygen and respiratory equipment must be submitted on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components to AFMC for beneficiaries of all ages. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. 220.000 PRIOR AUTHORIZATION221.000 Prosthetics Services Prior Authorization4-1-09Reimbursement for specified prosthetics services must be prior authorized. Prior authorization is required on items indicated (e.g., oxygen) or if the reimbursement for an item or items is $1000.00 or more (e.g., wheelchair and/or components). 221.100 Request for Prior Authorization9-1-18The request for prior authorization must originate with the prosthetics provider. The provider is responsible for obtaining the required medical information and prescription needed for completion of the prior authorization request form. A. The Medical Equipment Request for Prior Authorization and Prescription Form (Form DMS-679) will be used when requesting prior authorization for wheelchairs, wheelchair seating systems and wheelchair repairs. The primary care physician or advanced practice registered nurse within the scope of practice must sign the DMS-679. The primary care physicians or advanced practice registered nurses signature must be an original, not a stamp. Form DMS-679 must contain a diagnosis of the disease(s) necessitating use of prosthetics services. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679.doc"View or print form DMS-679 and instructions for completion. B. The Arkansas Foundation for Medical Care, Inc., (AFMC) reviews requests for prior authorization for some medical supplies (i.e., compression burn garments), orthotic appliances, prosthetic devices and durable medical equipment, excluding wheelchairs, wheelchair seating systems and wheelchair repairs. Form DMS-679A, titled Prescription and Prior Authorization Request for Medicaid Equipment Excluding Wheelchairs & Wheelchair Components must be completed for use with those items of durable medical equipment, excluding wheelchairs, wheelchair seating systems and wheelchair repairs. 221.200 Filing for Prior Authorization 4-6-15Requests for prior authorization will be handled by the Arkansas Foundation for Medical Care (AFMC). A. To request prior authorization for wheelchair and wheelchair seating systems, providers must use form DMS-679 and send the information to AFMC. The original and the first copy of the Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) must be forwarded to AFMC. The third copy of the form must be retained in the providers records. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/afmc.doc"View or print the AFMC contact information.  B. Requests for prior authorization of some medical supplies (i.e.: compression burn garments), orthotic appliances, prosthetic devices and all durable medical equipment, excluding wheelchairs and wheelchair seating systems, must be submitted to AFMC on the Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components Form (DMS-679A). HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A. 221.300 Approvals of Prior Authorization4-6-15A. The Arkansas Foundation for Medical Care (AFMC) reviews requests for prior authorization for wheelchair and wheelchair seating systems. If necessary, AFMC may request additional information. 1. When a request is approved for wheelchairs, wheelchair seating systems or wheelchair repair, a prior authorization control number will be assigned by AFMC. Determination of purchase, rental only, or capped rental will be made and an expiration date for rental only and capped rental items will be assigned. This information will be indicated on the copy of the form DMS-679 that is returned to the provider from AFMC within 30 working days of receipt of the prior authorization request. 2. Prior authorization may only be approved for a maximum of six (6) months (180 days) for beneficiaries of all ages. Within 30 working days before the end of currently prior authorized prosthetics services, the prosthetics provider must obtain a new prescription. If applicable, the provider must prepare and send a new Medical Equipment Request for Prior Authorization and Prescription Form (Form DMS-679), signed by the physician, to AFMC. 3. The effective date of the prior authorization will be the date on which the beneficiarys physician prescribed prosthetics services or the day following the last day of the previously prior authorized time period, whichever comes last. B. Consideration of prior authorization requests by AFMC requires correct completion of all fields on the request form. The prior authorization request form must contain current medical documentation necessitating use of the required prosthetics. If necessary, AFMC may request additional information. 1. When a PA request is approved, a prior authorization control number will be assigned by AFMC. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print AFMC contact information. Prior authorization approvals will be authorized for a maximum of six (6) months (180 days) for beneficiaries of all ages. The effective date of the prior authorization will be the date on which the beneficiarys physician prescribed prosthetics services or the day following the last day of the previously prior authorized time period, whichever comes last. 2. Within 30 working days before the end of currently authorized prosthetics services, the provider must obtain a new prescription. If applicable, the provider must prepare and submit a new Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components (form DMS-679A) signed by the prescribing physician. C. Providers should note the following authorization process exception. 1. Prior authorization numbers for capped rental items will be effective for the entire capped rental time period of 15 months. Therefore, only one prior authorization number is needed. a. Providers may use the one prior authorization number for billing of capped rental items for all 15 months. b. Previous prior authorization for an item will count toward the total 15-month period. c. Providers must resubmit a request for prior authorization after the first 180 days. d. Necessary information will be indicated on the copy of the notification letter sent to the provider within 30 working days of receipt of the prior authorization request. 221.400 Denial of Prior Authorization Request12-1-06For denied cases, both Utilization Review and AFMC will mail a letter containing case specific rationale that explains why the request was not approved to the requesting provider and to the Medicaid beneficiary within 30 working days of receipt of the prior authorization request. The provider may request reconsideration of the denial within thirty-five calendar days of the denial date. Requests must be made in writing and include additional documentation to substantiate the medical necessity of the requested services. Requests received after thirty-five calendar days of the denial date will not be accepted for reconsideration. 221.500 Reconsideration of Denials12-1-06If the denial decision is reversed during the reconsideration review, an approval is forwarded to the provider specifying the approved units and services. If the denial decision is upheld, the provider and the Medicaid beneficiary will be notified in writing of the review determination. Reconsideration is available only once per prior authorization request. However, if the denial is upheld during the reconsideration process, the provider may submit a new prior authorization request, for different dates of service, providing new supporting documentation is available. A subsequent prior authorization request will not be reviewed if it contains the same documentation submitted with the previous authorization and reconsideration requests. 221.600 Fair Hearing Request12-1-06The Medicaid beneficiary may request a fair hearing of a denied review determination made by either Utilization Review, Department of Health and Human Services (DHHS) or the Arkansas Foundation for Medical Care (AFMC). The fair hearing request must be in writing and sent to the Appeals and Hearings Section of DHHS within thirty-five calendar days of the date on the denial letter. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DHSAppealsHearings.doc"View or print the Department of Health and Human Services Appeals and Hearings Section contact information. Providers may refer to Section 190.000 for information regarding provider appeals through the Medicaid Fairness Act. 230.000 REIMBURSEMENT231.000 Prosthetics Service Method of Reimbursement10-13-03Reimbursement for prosthetics services is based on the lesser of the amount billed or the Title XIX (Medicaid) maximum allowable. Providers are cautioned that an approved prior authorization does not guarantee payment. Reimbursement is contingent upon eligibility of both the beneficiary and provider at the time service is provided and upon accurate completeness of the claim filed for the service. The provider is responsible for verifying the beneficiarys eligibility by checking the beneficiarys eligibility through the system. 231.010 Fee Schedule12-1-12Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at HYPERLINK "https://medicaid.mmis.arkansas.gov/"https://medicaid.mmis.arkansas.gov/ under the provider manual section. The fees represent the fee-for-service reimbursement methodology. Fee schedules do not address coverage limitations or special instructions applied by Arkansas Medicaid before final payment is determined. Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed. Information may be changed or updated at any time to correct a discrepancy and/or error. Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum. 232.000 Specialized Wheelchair, Seating and Rehabilitative Equipment Reimbursement for Repairs8-1-05Reimbursement for repairs of specialized wheelchairs will be the manufacturers list price for parts listed less 40% manual equipment (dealer discount), 30% power equipment (dealer discount), plus 35% (profit margin), plus labor billed by the unit (15 min. = 1 unit). A maximum of twenty (20) units (20 units = 5 hours of labor) per date of service is allowable. Any applicable pages from the manufacturers catalog and the manufacturers invoice for parts must be attached to the claim form. Reimbursement for specialized wheelchair equipment, seating and rehab items requiring manual pricing is calculated using the manufacturers current published suggested retail price less 15%. Any applicable pages from the manufacturers catalog that reflect a description and the manufacturers current published suggested retail price must be attached to the claim. Kaye Products will be reimbursed at a set rate; therefore, the Kaye Products (procedure codes E1031, modifiers EP, U1; E1031, modifiers EP, U3; and E1031, modifiers EP, U4) may be billed electronically. 233.000 Orthotic and Prosthetic Reimbursement for Repairs11-1-17Providers must bill for the repair of orthotic appliances and prosthetic devices utilizing the procedure codes listed in the table below. One unit of service equals 15 minutes. A maximum of 20 units of service is allowed per date of service. Any applicable pages from the manufacturers catalog and the manufacturers invoice for parts must be attached to all repair claims. National Procedure CodeRequired Modifier DescriptionL4205 L4210 L7510 L7520 Repair of orthotic appliances and prosthetic devices (non-EPSDT)L4205 L4210 L7510 L7520EP EP EP, UB Repair of orthotic appliances and prosthetic devices (EPSDT)Reimbursement for orthotic appliances and prosthetic devices requiring manual pricing will be calculated using the manufacturers invoice price plus 10%. The manufacturer invoice must be attached to all repair claims. 234.000 Durable Medical Equipment (DME) Reimbursement for Repairs8-1-05Reimbursement for repairs of durable medical equipment (DME) will be manufacturers invoice price for parts plus 10% and labor billed per unit (15 minutes = 1 unit of service). A maximum of twenty (20) units (20 units = 5 hours of labor) per date of service is allowable. The manufacturers invoice must be attached to the repair claim for all parts. Reimbursement for unlisted DME requiring manual pricing will be calculated using the manufacturers invoice price plus 10%. The manufacturers invoice must be attached to all repair claims. 235.000 Speech Generating Device Reimbursement for Repairs1-1-21Reimbursement for repairs of speech generating device components will be manufacturers invoice price for parts plus 10%. Labor will be reimbursed per unit of service (1 unit = 15 minutes limited to a maximum of 20 units per date of service allowed). 236.000 Reimbursement for Repair of the Enteral Nutrition Pump4-1-09Reimbursement for repairs to the enteral nutrition infusion pump requires prior authorization. Repairs will be approved only on equipment purchased by Medicaid. Therefore, no repairs will be reimbursable prior to the equipment becoming the property of the Medicaid beneficiary. Requests for prior authorization for enteral pump repairs must be mailed to AFMC. (HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc"View or print AFMC contact information) on form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components. (HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion.) The repair invoice and the serial number of the equipment must accompany the prior authorization request form. Total repair costs to an infusion pump may not exceed $290.93. Medicaid will not reimburse for additional repairs to an infusion pump after the provider has billed repair invoices totaling $290.93. If the equipment is still not in proper working order after the provider has billed the Medicaid maximum allowed for repairs, the provider must supply the beneficiary with a new infusion pump and may bill either procedure code B9000 or B9002 after receiving prior authorization for the new piece of equipment. 237.000 Rate Appeal Process8-1-05A provider may request reconsideration of a program decision by writing to the Assistant Director, Division of Medial Services. The request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate. Upon receipt of the request for review, the Assistant Director will determine the need for a program/provider conference and will contact the provider to arrange a conference if needed. Regardless of the program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the program/provider conference. When the provider disagrees with the decision of the Assistant Director, Division of Medical Services, the provider may appeal the question to a standing rate review panel established by the Director of the Division of Medical Services. The rate review panel will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Human Services (DHS) management staff, who will serve as chairperson. The request for review by the rate review panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical Services. The rate review panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The panel will hear the question(s) and a recommendation will be submitted to the Director of the Division of Medical Services. 240.000 billing procedures241.000 Introduction to Billing7-1-20Prosthetics providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one (1) beneficiary. Section III of this manual contains information about available options for electronic claim submission. 242.000 CMS-1500 Billing Procedures242.100 HCPCS Procedure Codes11-1-17242.105 Payment Methodology8-1-05Arkansas Medicaid has several methods of payment for all items covered by the Program. The following is a breakdown of the methods. A. Purchase items are equipment that is purchased for or purchased by an eligible Medicaid beneficiary. The equipment may be new or used. B. Rental-only items are those items paid by Arkansas Medicaid to providers for an unspecified time period on an as-needed basis. The equipment may be new or used. C. A capped rental item is equipment whose purchase price exceeds $150.00. The items may be new or used. The items are reimbursed utilizing a daily rental rate. Medicaid pays the daily rental rate not to exceed a fifteen- (15-) month rental maximum (455 days). A period of continuous use allows for periods of interruption up to 60 consecutive days. If the interruption is 60 or fewer consecutive days, a new 15-month rental period will not begin. If the interruption is more than 60 days, a new 15-month rental period will begin. D. After the total cost of a capped rental item has been reimbursed by Medicaid, the item remains the property of the DME provider. For items that have reached a 15-month rental cap, claims will be paid for maintenance and servicing fees after six months have passed from the end of the final paid rental month or from the end of the period the item is no longer covered under the suppliers or manufacturers warranty, whichever is later. E. Providers may be reimbursed for capped rental and rental-only items if the equipment is used fewer than 30 consecutive days from the first day of rental. This ensure the provider of adequate reimbursement for equipment used fewer than 30 days. F. A rent-to-purchase item is an item for which Arkansas Medicaid reimburses a provider for the Medicaid-established purchase price of the item. After reimbursement has reached the maximum allowed, the equipment will become the property of the Medicaid beneficiary. Reimbursement is only approved for new equipment. G. Initial rental transactions are those for which equipment is used in a beneficiarys home for fewer than 30 consecutive days. Initial rental transactions must not be used by the provider to bill a month in advance. Arkansas Medicaid will only pay after services are rendered. An example of an initial rental transaction is that of a hospital bed delivered on July 2 and removed from the home after 10 days. H. Manually priced items are those for which Arkansas Medicaid pays the manufacturers invoice price plus 10 percent. The provider must attach the invoice with their claim for services rendered. I. A used item is any item that has been rented for 90 days or longer by anyone prior to the current Medicaid rental only or capped rental transaction. The provider must maintain documentation that certifies a used item is reconditioned and in good working order and has no defect in workmanship or material. J. Repair of a rental only item is covered in the rental fee. Repair of purchased items is covered separately. Total (cumulative) repair costs must not exceed 50% of the items total purchase cost. 242.110 Respiratory and Diabetic Equipment, All Ages11-1-17When billed either electronically or on paper, procedure codes found in this section must be billed with certain modifiers. Modifiers in the section are indicated by the headings M1 and M2. When only the NU modifier is shown in the M1 column, the procedure code may be billed for beneficiaries of all ages. When NU and EP are listed together in the M1 column, the NU modifier must be used when billing for beneficiaries age 21 and over, and the EP modifier must be used when billing for beneficiaries under age 21. When a modifier is listed in the M2 heading, that modifier must be used in conjunction with either NU or EP. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, the information is indicated with a Y in the column; if not, an N is shown. ( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. (() This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. Respiratory and Diabetic Equipment, All Ages (Section 242.110)National Procedure CodeM1M2DescriptionPAPayment MethodA4230NUInfusion set for external insulin pump, non-needle cannula type YHYPERLINK \l "diamondexplination"(PurchaseA4231NUInfusion set for external insulin pump, needle typeYHYPERLINK \l "diamondexplination"(PurchaseA4232NUSyringe with needle for external insulin pump, sterile, 3 ccYHYPERLINK \l "diamondexplination"(PurchaseA4627NUUB((Spacer bag or reservoir without mask, for use with metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use with metered dose inhalerNPurchaseA4627NU((Spacer bag or reservoir with mask, for use with metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use with metered dose inhalerNPurchaseA7045NUExhalation port with or without swivel used with accessories for positive airway devices, replacement onlyNPurchaseA7046NUWater chamber for humidifier, used with positive airway pressure device, replacement, eachNPurchaseE0424NUStationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubingY(Rental OnlyE0430NUPortable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula or mask, and tubingY(Rental OnlyE0434NUPortable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adapter, contents gauge, cannula or mask, and tubingY(Rental OnlyE0435NUPortable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapterY(Rental OnlyE0439NUStationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubingY(Rental OnlyE0441NUOxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), one months supply = I unit YPurchaseE0442NUOxygen contents, liquid (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned), one months supply = 1 unit YPurchaseE0443NUPortable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary gas or liquid system is used), one months supply=1 unitY(PurchaseE0444NUPortable oxygen contents, liquid (for use only with portable liquid systems when no stationary gas or liquid system is used), one months supply=1 unitY(PurchaseE0470NU EPRR RR((BIPAP Device, Nasal Bi-level Positive Airway support system; includes necessary accessory items. NOTE: Complete medical data pertinent to the request must be submitted with the prior authorization request.) Respiratory assist device, bi-level pressure capacity, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)Y( Y(Rental OnlyE0471NU EPRR RRRespiratory assist device, bi-level pressure capacity, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)Y( Y(Rental OnlyE0472NU EPRR RRRespiratory assist device, bi-level pressure capacity, with backup rate feature, used with invasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)Y( Y(Rental OnlyE0482NUEPCough stimulating device, alternating positive and negative airway pressureYHYPERLINK \l "diamondexplination"(Capped RentalE0483NURR((Bronchial Drainage System) High-frequency chest wall oscillation air-pulse generator system (includes hoses and vest), eachYHYPERLINK \l "diamondexplination"(Capped Rental E0483NUUB((Pulmonary Vest. The manufacturer invoice must be attached to the claim form.) High-frequency chest wall oscillation air-pulse generator system (includes hoses and vest), eachYHYPERLINK \l "diamondexplination"(PurchaseE0560NU UEHumidifier, durable for supplemental humidification during IPPB treatment or oxygen deliveryNPurchaseE0561NU EPHumidifier, non-heated, used w/positive airway pressure deviceY( Y(PurchaseE0562NU EPHumidifier, heated, used w/positive airway pressure device Y( Y(PurchaseE0570NU UENebulizer, with compressorY(PurchaseE0575NU UENebulizer, ultrasonic, large volumeY(Capped RentalE0600NU UERespiratory suction pump, home model, portable or stationary, electricNRental OnlyE0601NURR((CPAP Device Nasal Continuous Positive Airway Pressure (CPAP) Device; includes necessary accessory items) NOTE: Complete medical data pertinent to the request must be submitted with the prior authorization request. NOTE: Bill E0601 as the global daily rental service.Y(Rental OnlyE0784NUExternal ambulatory infusion pump, insulinYHYPERLINK \l "diamondexplination"(PurchaseE1354NUOxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, each YManually pricedE1390NUOxygen concentrator, single delivery port, capable of delivering 85 % or greater oxygen concentration at the prescribed flow rateY(Rental OnlyE1391NUO2 concentrator, dual delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate, eachY(Rental Only  242.111 Initial Rental of a DME Item for Individuals of All Ages11-1-17Procedure codes found in this section may be billed either electronically or on paper. Some procedure codes have been assigned a modifier that affects the billing process. Required modifiers are indicated in the M1 column in the list below. When a modifier is shown in the M1 column, it must be listed along with the procedure code when requesting payment by Arkansas Medicaid. Procedure codes shown in the list below are either covered for all ages (AA), only for individuals under age 21 (U21) or only for individuals age 21 and over (21+). A column in the list below defines the differences. ( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. (() This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. Initial Rental of a DME Item for Individuals of All Ages (Section 242.111)National Procedure CodeM1DescriptionAll U21 21+E0181Pressure pad, alternating with pump, heavy-dutyU21E0200Heat lamp, without stand (table model), includes bulb, or infrared elementU21E0205Heat lamp, with stand includes bulb, or infrared elementU21E0217Water circulating heat pad with pumpU21E0225Hydrocollator unit, includes padU21E0236Pump for water circulating padU21E0239Hydrocollator unit, portableU21E0250HYPERLINK \l "diamondexplination"(Hospital bed, fixed height, with any type side rails, with mattressU21E0250HYPERLINK \l "diamondexplination"(U1Hospital bed, fixed height, with any type side rails, with mattressU21E0250HYPERLINK \l "diamondexplination"(UEHospital bed, fixed height, with any type side rails, with mattress21+E0255HYPERLINK \l "diamondexplination"(Hospital bed, variable height; hi-lo, with any type side rails, with mattressU21E0255KHHospital bed, variable height; hi-lo, with any type side rails, with mattress21+E0260HYPERLINK \l "diamondexplination"(Hospital bed, semi-electric (head and foot adjustment), with any type side rails with mattressU21E0260HYPERLINK \l "diamondexplination"(KHHospital bed, semi-electric (head and foot adjustment), with any type side rails with mattress21+E0271Mattress, inner springU21E0272Mattress, foam rubberU21E0303Hospital bed, heavy-duty, extra wide, with weight capacity > 350 but < or = 600, any type side rails, w/mattressAAE0424Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator flowmeter, humidifier, nebulizer cannula or mask, and tubingAAE0430HYPERLINK \l "diamondexplination"(Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula, or mask, and tubingAAE0434Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubingAAE0435HYPERLINK \l "diamondexplination"(Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapterAAE0439Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubingAAE0445HYPERLINK \l "diamondexplination"(Oximeter for measuring blood oxygen levels non-invasively. ( (Pulse oximeter, including 4 disposable probes)AAE0480Percussor, electric or pneumatic, home modelU21E0565HYPERLINK \l "diamondexplination"(Compressor, air power source for equipment which is not self-contained or cylinder drivenU21E0575HYPERLINK \l "diamondexplination"(Nebulizer, ultrasonic, large volumeAAE0585Nebulizer, with compressor and heaterU21E0600Respiratory suction pump, home model, portable or stationary, electricAAE0606Vaporizer, room typeU21E0630HYPERLINK \l "diamondexplination"(Patient lift, hydraulic, with seat or slingU21E0630KHPatient lift, hydraulic, with seat or sling21+E0650HYPERLINK \l "diamondexplination"(Pneumatic compressor, nonsegmental home modelU21E0667HYPERLINK \l "diamondexplination"(Segmental pneumatic appliance for use with pneumatic compressor, full legU21E0668HYPERLINK \l "diamondexplination"(Segmental pneumatic appliance for use with pneumatic compressor, full armU21E0691Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or lessU21E0692Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panelU21E0693Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panelU21E0694Ultraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protectionU21E0720HYPERLINK \l "diamondexplination"(TENS, two lead, localized stimulationU21E0730HYPERLINK \l "diamondexplination"(Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulationAAE0730HYPERLINK \l "diamondexplination"(KHTranscutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation21+E0745HYPERLINK \l "diamondexplination"(Neuromuscular stimulator, electronic shock unitU21E0779HYPERLINK \l "diamondexplination"(((Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion device pump, mechanical, reusable, for infusion 8 hours or greaterAAE0910Trapeze bars, also known as Patient Helper, attached to bed, with grab barAAE0910KHTrapeze bars, also known as Patient Helper, attached to bed, with grab bar21+E0911Trapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab barAAE0920Fracture frame, attached to bed, includes weights U21E0930Fracture frame, freestanding, includes weightsU21E0935HYPERLINK \l "diamondexplination"(Passive motion exercise deviceU21E0940Trapeze bar, freestanding, complete with grab barU21E0941Gravity assisted traction device, any typeU21E1130HYPERLINK \l "diamondexplination"(Standard wheelchair, fixed full-length arms, fixed or swingaway, detachable footrestsU21E1130HYPERLINK \l "diamondexplination"(KHStandard wheelchair, fixed full-length arms, fixed or swingaway, detachable footrests21+E1224HYPERLINK \l "diamondexplination"(Wheelchair with detachable arms, elevating legrestsAAE1224HYPERLINK \l "diamondexplination"(U1((Footrests wheelchair with detachable arms, elevating leg rests) Wheelchair with detachable arms, elevating legrests21+E1390Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rateAAE1391Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, eachAA Providers will be reimbursed for a minimum of 30 days of rental when the equipment is used less than 30 days. Initial rental codes must be billed when equipment is used less than 30 days during the first month of rental. Arkansas Medicaid will only reimburse for one initial minimum 30 days of rental per state fiscal year period per beneficiary per procedure code. The provider will not be reimbursed for the same procedure code utilizing another modifier for the same time period. 242.112 Home Blood Glucose Monitor and Supplies Pregnant Women Only, All Ages11-1-17Procedure codes found in this section must be billed either electronically or on paper with modifier NU for individuals of all ages. When a second modifier is listed, that modifier must be used in conjunction with the NU modifier. Modifiers in the section are indicated by the headings M1 and M2. Prior authorization is indicated by the heading PA. National Procedure CodeM1M2DescriptionPAPayment MethodE0607NUU1Home Blood Glucose MonitorNPurchaseA4253NUU1Blood glucose test or reagent strips for home glucose monitor, per 50 stripsNPurchaseA4259NUU2Lancets, per box of 100NPurchase 242.120 Medical Supplies for Beneficiaries of All Ages8-15-18Procedure codes found in this section must be billed either electronically or on paper using modifier NU for beneficiaries of all ages. When a second modifier is listed, that modifier must be used in conjunction with the modifier NU. Modifiers in this section are indicated by the headings M1 and M2 1 Not all medical supplies require prior authorization. Supplies with this symbol require prior authorization. Form DMS-679A must be used to request prior authorization. Note: Compression burn garments are manually priced. The manufacturers invoice must be submitted with the request for compression burn garments. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. (() This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. Medical Supplies, All Ages (Section 242.120)National Procedure CodeM1M2DescriptionA4206NUSyringe with needle, sterile, 1 cc., eachA4207NUSyringe with needle, sterile, 2 cc., eachA4209NUSyringe with needle, sterile, 5 cc. or greater, eachA4213NUSyringe, sterile, 20 cc. or greater, each A4216NUSterile water/saline and/or dextrose, diluent/flush, 10 ml.A4217NUSterile water/saline, 500 ml.A42211NUSupplies for maintenance of drug infusion catheter, per week (list drug separately)A42221NUSupplies for external drug infusion pump, per cassette or bag (list drug separately)A4224NUSupplies for maintenance of insulin infusion catheter, per weekA4225NUSupplies for external insulin infusion pump, syringe type cartridge, sterile, eachA4253NUUB((Blood glucose test or reagent strips for home blood glucose monitor, per 25 strips)A4253NUBlood glucose test or reagent strips for home blood glucose monitor, per 50 stripsA4256NUNormal, low, and high calibrator solution/chipsA4259NULancets, per box of 100A4265NUParaffin, per lb.A4310NUInsertion tray without drainage bag and without catheter (accessories only)A4311NUInsertion tray without drainage bag with indwelling catheter, Foley type, 2-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)A4312NUInsertion tray without drainage bag with indwelling catheter, Foley type, 2-way, all siliconeA4313NUInsertion tray without drainage bag with indwelling catheter, Foley type, 3-way, for continuous irrigationA4314NUInsertion tray with drainage bag with indwelling catheter, Foley type, 2-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)A4315NUInsertion tray with drainage bag with indwelling catheter, Foley type, 2-way, all siliconeA4316NUInsertion tray with drainage bag with indwelling catheter, Foley type, 3-way, for continuous irrigationA4320NUIrrigation tray with bulb or piston syringe, any purposeA4322NUIrrigation syringe, bulb or piston, eachA4326NUMale external catheter with integral collection chamber, any type eachA4327NUFemale external urinary collection device; metal cup, eachA4328NUFemale external urinary collection device; pouch, eachA4330NUPerianal fecal collection pouch with adhesive, eachA4331NUExtension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, eachA4338NUIndwelling catheter, Foley type, 2-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), eachA4340NUIndwelling catheter; specialty type (e.g., Coude, mushroom, wing, etc.), eachA4344NUIndwelling catheter, Foley type, 2-way, all silicone, eachA4346NUIndwelling catheter, Foley type, 3-way for continuous irrigation, eachA4349NUMale external catheter with or without adhesive, disposable, eachA4351NUIntermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), eachA4351NUU1Intermittent urinary catheter; disposable straight tip, with or without coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.), eachA4352NUIntermittent urinary catheter; Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric or hydrophilic, etc.), eachA4352NUU1Intermittent urinary catheter; Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric or hydrophilic, etc.), eachA4353NUIntermittent urinary catheter, with insertion suppliesA4353NUU2Intermittent urinary catheter, with insertion suppliesA4354NUInsertion tray with drainage bag but without catheterA4355NUIrrigation tubing set for continuous bladder irrigation through a 3-way indwelling Foley catheter, eachA4356NUExternal urethral clamp or compression device (not to be used for catheter clamp), eachA4357NUBedside drainage bag, day or night, with or without anti reflux device, with or without tube, eachA4358NUUrinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, eachA4361NUOstomy faceplate, eachA4362NUSkin barrier; solid, four by four or equivalent; eachA4364NUAdhesive, liquid, or equal, any type, per oz.A4367NUOstomy belt, eachA4368NUOstomy filter, any type, eachA4369NUOstomy skin barrier, liquid, (spray, brush, etc.), per oz.A4371NUOstomy skin barrier, powder, per oz.A4394NUOstomy deodorant, with or without lubricant, for use in ostomy pouch, per fl. oz.A4397NUIrrigation supply; sleeve, eachA4398NUOstomy irrigation supply; bag, eachA4399NUOstomy irrigation supply; cone/catheter, including brushA4400NUOstomy irrigation setA4402NULubricant, per oz.A4404NUOstomy ring, eachA4405NUOstomy skin barrier, nonpectin-based, paste, per oz.A4406NUOstomy skin barrier, pectin-based, paste, per oz.A4407NUOstomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 in. or smaller, eachA4414NUOstomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 in. or smaller, eachA4425NUOstomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), eachA4435NUOstomy pouch, drainable, high output, with extended wear barrier (one piece system), with or without filter, eachA4450NUU1Tape, nonwaterproof, per 18 sq. in.A4452NUTape, waterproof, per 18 sq. in.A4455NUAdhesive remover or solvent (for tape, cement or other adhesive), per oz.A4456NUAdhesive remover; any typeA4483NUU1((non-vent, trach nose) Moisture exchanger, disposable, for use with invasive mechanical ventilationA4558NUConductive gel or paste, for use with electrical device (e.g., TENS, NMES), per oz.A4561NUU1Pessary, rubber, any typeA4562NUPessary, non-rubber, any typeA4623NUTracheostomy, inner cannulaA4624NUTracheal suction catheter, any type other than closed system, eachA4625NUTracheostomy care kit for new tracheostomyA4626NUTracheostomy cleaning brush, eachA4628NUOropharyngeal suction catheter, eachA4629NUTracheostomy care kit for established tracheostomyA4772NUBlood glucose test strips, for dialysis, per 50A4927NUGloves, non-sterile, per 100A5051NUOstomy pouch, closed; with barrier attached (1 piece), eachA5052NUOstomy pouch, closed; without barrier attached (1 piece), eachA5053NUOstomy pouch, closed; for use on faceplate, eachA5054NUOstomy pouch, closed; for use on barrier with flange (2 piece), eachA5055NUStoma capA5056NUOstomy pouch, drainable; with extended wear barrier attached, with filter, 1 piece, eachA5057NUOstomy pouch, drainable; with extended wear barrier attached, with built in convexity, with filter, 1 piece, eachA5061NUU1Ostomy pouch, drainable; with barrier attached (1 piece), eachA5062NUOstomy pouch, drainable; without barrier attached (1 piece), eachA5063NUOstomy pouch, drainable; for use on barrier with flange (2-piece system), eachA5071NUOstomy pouch, urinary; with barrier attached (1 piece), eachA5072NUOstomy pouch, urinary; without barrier attached (1 piece), eachA5073NUOstomy pouch, urinary; for use on barrier with flange (2 piece), eachA5081NUContinent device; plug for continent stomaA5082NUContinent device; catheter for continent stomaA5093NUOstomy accessory; convex insertA5102NUBedside drainage bottle, with or without tubing, rigid or expandable, eachA5105NUUrinary suspensory with leg bag, with or without tube, eachA5112NUUrinary leg bag; latexA5113NULeg strap; latex, replacement only, per setA5114NULeg strap; foam or fabric, replacement only, per setA5120NUSkin barrier, wipes or swabs, eachA5121NUSkin barrier; solid, 6 x 6 or equivalent, eachA5122NUSkin barrier; solid, 8 x 8 or equivalent, eachA5126NUAdhesive or non-adhesive; disk or foam padA5131NUAppliance cleaner, incontinence and ostomy appliances, per 16 oz.A6021NUCollagen dressing, sterile, size 16 sq. in. or less, eachA6022NUCollagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., eachA6023NUCollagen dressing, sterile, size more than 48 sq. in., eachA6024NUCollagen dressing wound filler, sterile, per 6 in.A6154NUWound pouch, eachA6196NUAlginate or other fiber gelling dressing, wound cover, pad size 16 sq. in. or less, each dressingA6197NUAlginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressingA6197NUUBAlginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing ((1 linear yard)A6198NUAlginate or other fiber gelling dressing, wound cover, sterile, pad size more than 48 sq. in., each dressingA6203NUComposite dressing, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressingA6204NUComposite dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressingA6205NUComposite dressing, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressingA6209NUFoam dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressingA6210NUFoam dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressingA6211NUFoam dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressingA6212NUFoam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressingA6213NUFoam dressing, wound cover, sterile, pad size more than 16 sq. in but less than or equal to 48 sq. in., with any size adhesive border, each dressingA6216NUGauze, nonimpregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressingA6219NUGauze, nonimpregnated, sterile, 16 sq. in. or less with any size adhesive border, each dressingA6220NUGauze, non-impregnated, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., with any size adhesive border, each dressingA6221NUGauze, non-impregnated, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressingA6228NUGauze, impregnated, water or normal saline, sterile, pad, size 16 sq. in. or less, without adhesive border, each dressingA6229NUGauze, impregnated, water or normal saline, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressingA6230NUGauze, impregnated, water or normal saline, sterile, pad size more than 48 sq. in., without adhesive border, each dressingA6234NUHydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressingA6234NUU1((Hydrocolloid dressing, wound cover, sterile, pad size greater than 16 sq. in. , without adhesive border, each dressing)A6235NUHydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressingA6236NUHydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressingA6237NUHydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressingA6237NUU1((Hydrocolloid dressing, wound cover, sterile, pad size greater than 16 sq. in., with any size adhesive border, each dressing)A6238NUHydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressingA6238NUU1Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressingA6239NUHydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressingA6241NUHydrocolloid dressing, wound filler, dry form, sterile, per gramA6242NUHydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressingA6242NUU1((Hydrogel dressing, wound cover, sterile, pad size greater than 16 sq. in., without adhesive border, each dressing)A6243NUHydrogel dressing, wound cover, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressingA6244NUHydrogel dressing, wound cover, sterile, pad size more than 48 sq. in. without adhesive border, each dressingA6245NUHydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressingA6246NUHydrogel dressing, wound cover, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., with any size adhesive border, each dressingA6247NUHydrogel dressing, wound cover, sterile, pad size more than 48 sq. in. with any size adhesive border, each dressingA6248NUHydrogel dressing, wound filler, gel, sterile, per fl. oz.A6248NUU1Hydrogel dressing, wound filler, gel, sterile, per fl. oz.A6257NUTransparent film, sterile, 16 sq. in. or less, each dressingA6258NUTransparent film, sterile, more than 16 sq. in., but less than or equal to 48 sq. in., each dressingA6259NUTransparent film, sterile, more than 48 sq. in., each dressingA6403NUGauze, nonimpregnated, sterile, pad size more than 16 sq. in. less than 48 sq. in., without adhesive border, each dressingA6404NUGauze, nonimpregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressingA6441NUPadding bandage, nonelastic, nonwoven/nonknitted, width greater than or equal to 3 in. and less than 5 in., per yd.A6442NUConforming bandage, nonelastic, knitted/woven, nonsterile, width less than 3 in., per yd.A6443NUConforming bandage, nonelastic, knitted/woven, nonsterile, width greater than or equal to 3 in. and less than 5 in., per yd.A6444NUConforming bandage, nonelastic, knitted/woven, nonsterile, width greater than or equal to 5 in., per yd.A6445NUConforming bandage, nonelastic, knitted/woven sterile, width less than 3 in., per yd.A6446NUConforming bandage, nonelastic, knitted/woven, sterile, width greater than or equal to 3 in. and less than 5 in., per yd.A6447NUConforming bandage, nonelastic, knitted/woven, sterile, width greater than or equal to 5 in., per yd.A6448NULight compression bandage, elastic, knitted/woven width less than 3in., per yd.A6449NULight compression bandage, elastic, knitted/woven, width greater than or equal to 3 in. and less than 5 in., per yd.A6450NULight compression bandage, elastic, knitted/woven, width greater than or equal to 5 in., per yd.A6451NUModerate compress bandage, elastic, knitted/woven load resistance of 1.25 to 1.34 ft. lbs. at 50% maximum stretch, width greater than or equal to 3 in. and less than 5 in., per yd.A6452NUHigh compress bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 ft. lbs. at 50 % maximum stretch, width greater than or equal to 3 in. and less than 5 in., per yd.A6453NUSelf-adherent bandage, elastic, nonknitted/nonwoven, width less than 3 in., per yd.A6454NUSelf-adherent bandage, elastic, nonknitted/nonwoven, width greater than or equal to 3 in and less than 5 in., per yd.A6455NUSelf-adherent bandage, elastic, nonknitted/nonwoven, width greater than or equal to 5 in., per yd.A65011NUCompression burn garment, bodysuit (head to foot), custom fabricatedA65021NUCompression burn garment, chin strap, custom fabricatedA65031NUCompression burn garment, facial hood, custom fabricatedA65041NUCompression burn garment, glove to wrist, custom fabricatedA65051NUCompression burn garment, glove to elbow, custom fabricatedA65061NUCompression burn garment, glove to axilla, custom fabricatedA65071NUCompression burn garment, foot to knee length, custom fabricatedA65081NUCompression burn garment, foot to thigh length, custom fabricatedA65091NUCompression burn garment, upper trunk to waist including arm openings (vest), custom fabricatedA65101NUCompression burn garment, trunk including arms down to leg openings (leotard), custom fabricatedA65111NUCompression burn garment, lower trunk including leg openings (panty), custom fabricatedA65121NUCompression burn garment, not otherwise classifiedA65131NUCompression burn mask, face and/or neck, plastic or equal, custom fabricatedA7520NUTracheostomy/laryngectomy tube, noncuffed, polyvinylchloride (PVC), silicone or equal, eachA7521Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, eachA7522Tracheostomy/laryngectomy tube, stainless steel or equal, (sterilizable and reusable), eachA7524Tracheostoma stent/stud/button, eachA7525Tracheostomy mask, eachB4087NUGastrostomy/jejunostomy tube, standard, any material, any type, eachE0776NUIV poleE0779NURR((Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greaterJ1642NUInjection, heparin sodium, (heparin lock flush), per 10 units 242.121 Food Thickeners, All Ages11-1-17Food thickeners, including Thick-It, Thick-It II, Simply Thick, Thick and Easy and Thick and Clear are not subject to the $250 medical supply benefit limit. The modifier NU must be used with the procedure code found in this section and when food thickeners are to be administered enterally, the modifier BA must be used in conjunction with the procedure code. When food thickeners are billed, total units are to be calculated to the nearest full ounce. Partial units may not be rounded up. When a date span is billed, the product cannot be billed until the end date has elapsed. The maximum number of units allowed for food thickeners is 16 units per date of service. National Procedure CodeM1M2DescriptionB4100NUFood thickener, administered orally, per oz.B4100NUBAFood thickener, administered enterally, per oz. 242.122 Jobst Stocking for Beneficiaries of All Ages11-1-17The gradient compression stocking (Jobst) is payable for beneficiaries of all ages. However, before supplying the item, the Jobst stocking must be prior authorized by AFMC. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A and instructions for completion. Documentation accompanying form DMS-679A must indicate that the beneficiary has severe varicose veins with edema, or a venous statis ulcer, unresponsive to conventional therapy such as wrappings, over-the-counter stockings and Unna boots. The documentation must include clinical medical records from a physician detailing the failure of conventional therapy. National Procedure CodeM1M2DescriptionMaximum UnitsA6530NU EPGradient compression stocking, below knee, 18-30mm Hg, eachMaximum 4 units per date of serviceA6549NUGradient compression stocking, NOS (Jobst); 1 unit = 1 stockingMaximum 4 units per date of service 242.123 Negative Pressure Wound Therapy Pump Accessories and Supplies for Beneficiaries Ages 2 Years and Older11-1-17Effective for dates of service on or after May 11, 2012, procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries aged 2-20 years or modifier NU for beneficiaries aged 21 and over. Modifiers in this section are indicated by the heading M1. Prior authorization is indicated by the heading PA. If prior authorization is required, that information is indicated with a Y in the column, or if not, an N is shown. Negative Pressure Wound Therapy Pump Accessories and Supplies for Beneficiaries Ages 2 Years and Older (Section 242.123)National Procedure CodeM1DescriptionPAAge RestrictionA6550NUWound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessoriesY21 years and overA6550EPWound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessoriesY2-20 yearsA7000NUDisposable canister, used with suction pump, eachY21 years and overA7000EPDisposable canister, used with suction pump, each Y2-20 yearsE2402NUNegative pressure wound therapy electrical pump, stationary or portableY21 years and overE2402EPNegative pressure wound therapy electrical pump, stationary or portableY2-20 years 242.130 Diapers and Underpads for Beneficiaries Ages 3 Years and Older11-1-17Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU. Modifiers in this section are indicated by the headings M1 and M2. Prior authorization is indicated by the heading PA. If prior authorization is required, that information is indicated with a Y in the column, or if not, an N is shown. (() This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. Diapers and Underpads, 3 Years Old and Older (Section 242.130)National Procedure CodeM1M2DescriptionPAPayment MethodA4335NUUBIncontinence supply; miscellaneousNPurchaseA4554NUDisposable underpads, all sizes (e.g., Chuxs)NPurchaseT4521NUAdult-sized disposable incontinence product, brief/diaper, small, eachNPurchaseT4522NUAdult-sized disposable incontinence product, brief/diaper, medium, each NPurchaseT4523NUAdult-sized disposable incontinence product, brief/diaper, large, each NPurchaseT4524NUAdult-sized disposable incontinence product, brief/diaper, extra large, eachNPurchaseT4526NU EPAdult-sized disposable incontinence product, protective underwear/pull-on, medium size, eachNPurchaseT4527NU EPAdult-sized disposable incontinence product, protective underwear/pull-on, large size, eachNPurchaseT4528NU EPAdult-sized disposable incontinence product, protective underwear/pull-on, extra large size, eachNPurchaseT4529EP((Small diaper) Pediatric-sized disposable incontinence product, brief/diaper, small/medium size, eachNPurchaseT4529EPU1((Medium diaper) Pediatric-sized disposable incontinence product, brief/diaper, small/medium size, eachNPurchaseT4530NU EPPediatric-sized disposable incontinence product, brief/diaper, large size, eachNPurchaseT4531EP((Small diaper) Pediatric-sized disposable incontinence product, protective underwear/pull-on, small/medium size, eachNPurchaseT4531EPU1((Medium diaper) Pediatric-sized disposable incontinence product, protective underwear/pull-on, small/medium size, eachNPurchaseT4532NU EP((Large diaper) Pediatric-sized disposable incontinence product, protective underwear/pull-on, large size, eachNPurchaseT4532NU EPU1 U1((Extra large diaper) Pediatric-sized disposable incontinence product, protective underwear/pull-on, large size, eachNPurchaseT4533NU EPYouth-sized disposable incontinence product, brief/diaper, eachNPurchaseT4535NU EP((Pantyliners/Bladder Pads/Diaper Doubles) Disposable liner/shield/guard/pad/ undergarment for incontinence, eachNPurchaseT4535NU EPU1 U1((Under Garment One Size Fits All) Disposable liner/shield/guard/pad/ undergarment for incontinence, eachNPurchaseT4543NUDisposable incontinence product, brief/diaper, bariatric, eachNPurchaseT4544NUAdult-sized disposable incontinence product, protective underwear/pull-on, above extra large each Reimbursement is based on a per unit basis with one unit equaling one item (diaper, underpad). When billing for these services that are benefit limited to a dollar amount per month, providers must bill according to the calendar month. Providers must not span calendar months when billing for diapers and/or underpads. The date of delivery is the date of service. Providers should not bill from and through dates of service. Refer to Section 212.100 of this manual for coverage information on diapers and underpads. 242.140 Electronic Blood Pressure Monitor and Cuff, All Ages11-1-17The procedure code found in this section must be billed either electronically or on paper using modifier NU for individuals of all ages. Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a Y in the column; if not, an N is shown. (Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. National Procedure CodeM1M2DescriptionPAPayment MethodA4670NUAutomatic blood pressure monitorYHYPERLINK \l "diamondexplination"(Rental Only Included with the rental of this monitor, the provider will need to supply one (1) disposable blood pressure cuff each month. 242.150 Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries Under Twenty-one (21) Years of Age12-1-20The following list provides the enteral formula HCPCS procedure codes, any associated modifiers, code descriptions, and the formula covered for each HCPCS code. The code description lists the formula included in the category of nutrients. The coverage listed is payable only if the service is prescribed as a result of a Child Health Services (EPSDT) screening/referral. No prior authorization is required for nutritional formulae for EPSDT beneficiaries from age five (5) years through twenty (20) years. Prior authorization is required for beneficiaries from birth through four (4) years. Use of modifier U7 in the following list will be necessary, as indicated. To request prior authorization, providers should complete the Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components (DMS-679A), attaching a copy of the EPSDT screening/referral as well as a prescription signed by the beneficiarys PCP. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679A.doc"View or print form DMS-679A.  HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/AFMC.doc" View or print contact information for how to submit the request. NOTE: The Women, Infant, and Children program (WIC) must be accessed before the Medicaid program for children from birth to five (5) years of age. The Arkansas Medicaid program mirrors coverage of approved WIC nutritional formulae. As stated in current policy, the WIC Program must be accessed first for Arkansas Medicaid beneficiaries aged zero (0) to five (5) years, prior to requesting supplemental amounts of WIC-approved nutritional formula. The Medicaid nutritional formula list will be updated accordingly to continue compliance with the WIC Program in Arkansas. Changes will be reflected in the appropriate Medicaid provider manual. For beneficiaries from birth through four (4) years of age, the use of modifier U8, as well as additional documentation, will be required when a non-WIC formula is prescribed, or WIC guidelines are not followed when prescribing special formula. An EPSDT screening, which documents the PCPs medical rationale for prescribing a formula, as well as medical records documenting the beneficiarys failed trials of WIC formula, must be submitted for review. Flavor preferences for formulae will not be considered for medical necessity. Exceptions to Use of Formulae The following exceptions must be followed in order to use formulae listed in this section. A. Nutramigen LIPIL Sensitivity or allergy to milk or soy protein; chronic diarrhea, food allergies, GI bleeds. Similac Advance must first have been tried. B. Nutramigen Enflora LGG Sensitivity or allergy to milk or soy protein; chronic diarrhea, food allergies, GI bleeds. Similac Advance must first have been tried. C. Pregestimil Allergy to milk or soy protein; chronic diarrhea, short gut; cystic fibrosis; fat malabsorption due to GI or liver disease. D. Gerber Extensive HA Allergy to milk or soy protein; severe malnutrition; chronic diarrhea; short bowel syndrome; known or suspected corn allergy. Similac Advance must first have been tried. E. Alfamino Junior Allergy to cows milk, multiple food protein intolerance, and food allergy associated conditions: short bowel syndrome, gastroesophageal reflux disease (GERD), eosinophilic esophagitis, malabsorption, and other GI disorders. Neocate Junior with Prebiotics is intended for children over the age of one (1) year. F. Alfamino Infant Allergy to cows milk, multiple food protein intolerance, and food allergy associated conditions: short bowel syndrome, gastroesophageal reflux disease (GERD), eosinophilic esophagitis, malabsorption, and other GI disorders. Similac Expert Care Alimentum, Nutramigen, or Pregestimil must first have been tried. G. Portagen Pancreatic insufficiency, bile acid deficiency, or lymphatic anomalies; biliary atresia; liver disease; chylothorax. H. Similac PM 60/40 Renal, cardiac, or other condition that requires lowered minerals. I. Periflex Infant PKU; Hyperphenylalaninemia; for infants and toddlers. J. PKU Periflex Junior Plus Hyperphenylalaninemia; for children and adults. K. Gerber Good Start Premature 24 Preterm, low birth weight. Not intended for feeding low birth weight infants after they reach a weight of 3600 g (approximately eight (8) lbs.). Not approved for an infant previously on term formula or a term infant for increased calories. L. Enfamil EnfaCare Preterm infant transitional formula for use between premature formula and term formula. Not approved for an infant previously on term formula or a term infant for increased calories. Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under twenty-one (21) years of age. Modifier BO is used to bill for oral usage. When a second or third modifier is listed, that modifier must be used in conjunction with EP. For beneficiaries from birth through four (4) years of age, the use of modifier U7, as well as additional documentation will be required when a non-WIC formula is prescribed, or WIC guidelines are not followed when prescribing special formula. Modifiers in this section are indicated by the headings M1, M2, M3 and M4. Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries Under Twenty-one (21) Years of Age (Section 242.150)National Procedure CodeM1M2M3M4DescriptionCovered FormulaeB4149 B4149 B4149 B4149 Ages 0 4 Years requires PAEP EP EP EP BO U7 U7 BOEnteral formula, blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unitB4150 B4150 B4150 B4150 Ages 0 4 Years requires PAEP EP EP EP BO U7 U7 BOEnteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unitB4150 B4150 Ages 0 4 Years requires PAEP EPU1 U1BO U7 BOEnteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unitB4152 B4152 B4152 B4152 Ages 0 4 Years requires PAEP EP EP EP BO U7 U7 BOEnteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 Kcal/ml), with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unitB4153 B4153 B4153 B4153 Ages 0 4 Years requires PAEP EP EP EP BO U7 U7 BOEnteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unitB4154 B4154 B4154 B4154 Ages 0 4 Years requires PAEP EP EP EP BO U7 U7 BOEnteral formula, nutritionally complete, for special metabolic needs, includes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins, or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unitB4155 B4155EP EP BOEnteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unitMCT Oil Procel Protein Supplement Provimin B4155 B4155 Ages 0 4 Years requires PAEP EP U7 BOEnteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unitMCT Oil Procel Protein Supplement ProviminB4155 B4155 B4155 B4155 Ages 0 4 Years requires PAEP EP EP EPU1 U1 U1 U1 BO U7 U7 BOEnteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unitSolCarb ScandicalB4155 B4155 B4155 B4155 Ages 0 4 Years requires PAEP EP EP EPU2 U2 U2 U2 BO U7 U7 BOEnteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unitMicrolipidB4155 B4155 B4155 B4155 Ages 0 4 Years requires PAEP EP EP EPU3 U3 U3 U3 BO U7 U7 BOEnteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unitB4158 B4158 B4158 B4158 Ages 0 4 Years requires PAEP EP EP EP BO U7 U7 BOEnteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, or iron, administered through an enteral feeding tube, 100 calories = 1 unitB4159 B4159 B4159 B4159 Ages 0 4 Years requires PAEP EP EP EP BO U7 U7 BOEnteral formula, for pediatrics, nutritionally complete soy base with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, or iron, administered through an enteral feeding tube, 100 calories = 1 unitB4159 B4159 B4159 B4159 Ages 0 4 Years requires PAEP EP EP EP BO U8 U8 U7 U7 BOEnteral formula, for pediatrics, nutritionally complete soy base with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, or iron, administered through an enteral feeding tube, 100 calories = 1 unitB4160 B4160 B4160 B4160 Ages 0 4 Years requires PAEP EP EP EP BO U7 U7 BOEnteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unitB4160 B4160 B4160 B4160 Ages 0 4 Years requires PAEP EP EP EP BO U8 U8 U7 U7 BOEnteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unitB4160 B4160 B4160 B4160 Ages 0 4 Years requires PAEP EP EP EPU1 U1 U1 U1 BO U7 U7 BOEnteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unitB4160 B4160 Ages 0 4 Years requires PAEP EPU1 U1U8 U8 BOEnteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unitB4161 B4161 B4161 B4161 Ages 0 4 Years requires PAEP EP EP EP BO U7 U7 BOEnteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unitB4161 B4161 B4161 B4161 Ages 0 4 Years requires PAEP EP EP EP BO U7 U7 U8U8 BOEnteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unitB4162 B4162 B4162 B4162 Ages 0 4 Years requires PAEP EP EP EP BO U7 U7 BOEnteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unitB4162 B4162 B4162 B4162 Ages 0 4 Years requires PAEP EP EP EPU1 U1 U1 U1 BO U7 U7 BOEnteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit One (1) unit of service equals one-hundred (100) calories with a reimbursable maximum of thirty (30) units per day. Supplies furnished by prosthetics providers in conjunction with the nutritional formula must be billed to Medicaid with the prosthetics medical supply codes. These formulae are covered as nutritional supplements rather than as the sole source of nutrition. NOTE: Beneficiaries who require enteral nutrition as the sole source of nutrition with the formulae being administered through a nasogastric, jejunostomy or gastrostomy tube should be referred to a hyperalimentation provider enrolled in the Medicaid Program. Each claim should reflect a from and through date of service. The claims must not be filed until after the through date has elapsed. Claims may be submitted on either a weekly or a monthly basis. 242.151 Pedia-Pop11-1-17The procedure code found in this section must be billed with modifier EP. Pedia-Pop is only for oral consumption, and is only in frozen form. Modifiers in this section are indicated by the headings M1 and M2. National Procedure CodeM1M2DescriptionMaximum UnitsDeleted Local CodeB4103EPU1(Pedia-Pop; 1 unit equals 1 box2 units per date of serviceZ2487 242.152 Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supply Kit11-1-17Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age. When a second modifier is listed, that modifier must be used in conjunction with EP. The procedure codes require prior authorization from AFMC. Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a Y in the column; if not, an N is shown. (() This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. National Procedure CodeM1M2DescriptionMaximum UnitsPAPayment MethodB4035EPEnteral feeding supply kit, pump fed, per day (1 unit = 1 day)1 per dayYPurchaseB9000EPEnteral nutrition infusion pump without alarm (1 day = 1 unit)1 per dayYRent to PurchaseB9002EPEnteral nutrition infusion pump with alarm (1 day = 1 unit)1 per dayYRent to PurchaseK0739EPU2((Repair or non-routine service for enteral nutrition infusion pump, requiring the skill of a technician, parts and labor)Y Enteral Nutrition Infusion Pump Reimbursement for the enteral nutrition infusion pump is based on a rent-to-purchase methodology. Each unit reimbursed by Medicaid will apply towards the purchase price established by Medicaid. Reimbursement will only be approved for new equipment. Used equipment will not be prior authorized. Procedure codes B9000 and B9002 represent a new piece of equipment being reimbursed by Medicaid on the rent-to-purchase plan. Codes B9000 and B9002 are reimbursed on a per unit basis with 1 day equaling 1 unit of service per day. Medicaid will reimburse on the rent-to-purchase plan for a total of 304 units of service. After reimbursement has been made for 304 units, the equipment will become the property of the Medicaid beneficiary. Prior authorization is required for codes B9000 and B9002. The prior authorization request must include the serial number of the infusion pump being provided to the beneficiary. See Section 236.000 for reimbursement when the Medicaid Program is billed for repairs made to the enteral infusion pump. 242.153 Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) and Low-Profile Percutaneous Cecostomy Tube and Supplies for Beneficiaries of All Ages12-1-20NOTE: When billing for the Low-Profile Percutaneous Cecostomy Tube or supplies, an additional third modifier UA will be required. Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. National Procedure CodeM1M2PADescriptionPayment MethodB9998YLow-Profile KitPurchaseB9998NUU1YSECUR-LOK Extension Set with 2 Port Y and Clamp 12 LengthPurchaseB9998NUU2YSECUR-LOK Extension Set with 2 Port Y and Clamp 24 LengthPurchaseB9998NUU3YBolus Extension Set with Single Port Clamp 12 LengthPurchaseB9998NUU4YBolus Extension Set with Single Port Clamp 24 LengthPurchaseB9998NUU5YBolus SECUR-LOK Extension Set Single Port w/Clamp 12 LengthPurchaseB9998NUU6YBolus SECUR-LOK Extension Set Single Port w/Clamp 24 LengthPurchaseB9998NUU7YMicrovasive AdapterPurchaseB9998NUU8YMicrovasive Decompression TubePurchase 242.154 Nasogastric Tubing for Individuals Under Age 2111-1-17The procedure code found in this section must be billed with modifier EP for beneficiaries under 21years of age. The code is payable only for beneficiaries under age 21. National Procedure CodeM1M2PADescriptionPayment MethodB4082EPNNasogastric tubing without styletPurchase 242.155 Billing and Reimbursement Protocol for FM (Frequency Modulation) System and Replacement Cochlear Implant Parts11-1-17Procedure codes L8621, L8622 and L8624 in the table below require paper claim submission with a manufacturers invoice attached that demonstrates the specific cost per item. The invoice must clearly indicate the specific item(s) supplied to the beneficiary for whom the claim is billed. Procedure codes L8615, L8616, L8617, L8618, L8619, L8623, L8627, L8628 and L8629 may be submitted electronically or on a paper claim form. Procedure code V5273 may be submitted electronically or on a paper claim form. For provider charges for an FM system that is meant to be used with a cochlear implant, V5273 should reflect the retail price. For reimbursement of an FM system to be used with a cochlear implant, V5273 will be at 68 percent of the retail price. National Procedure CodeM1DescriptionPAPA CriteriaUnits Allowed per Date of ServiceL8615*EPHeadset/headpiece for use with cochlear implant device, replacementY1 per 3 years2L8616*EPMicrophone for use with cochlear implant device, replacementY1 per year2L8617*EPTransmitting coil for use with cochlear implant device, replacementY1 per year2L8618*EPTransmitter cable for use with cochlear implant device, replacementY4 per 6 months8L8619*EPCochlear implant external speech processor, and controller, integrated system, replacementY5 years2L8621*EPZinc air battery for use with cochlear implant device replacement, eachY180 units per 6 months360L8622*EPAlkaline battery for use with cochlear implant device, any size, replacement, eachY180 units per 6 months360L8623*EPLithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, eachY1 (set of 2) per year Unilateral2L8624*EPLithium ion battery for use with cochlear implant device speech processor, ear level, replacement, eachY1 (set of 2) per year Unilateral2L8627*EPCochlear implant, external speech processor, component, replacementYPrior authorized when not under warranty2L8628*EPCochlear implant, external controller component, replacementYPrior authorized when not under warranty2L8629*EPTransmitting coil and cable, integrated, for use with cochlear implant device, replacementY1 per year2V5273EPAssistive listening device, for use with cochlear implantYPrior authorized when not covered through IDEA1 *Denotes paper claim 242.160 Durable Medical Equipment, All Ages11-1-17Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU. Modifier UE is required when billing for used equipment. Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a Y in the column; if not, an N is shown. * The purchase of wheelchairs for individuals age 21 and older is limited to one per five-year period. *** This procedure code may not be billed for used equipment. ( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. (() This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. 3 This item is a capped rental for 90 days only, and requires PA and a review. Durable Medical Equipment, All Ages (Section 242.160)National Procedure CodeM1M2M3PADescriptionPayment MethodA4566NU EPNShoulder sling or vest design, abduction restrainer, with or without swathe control, prefabricated, includes fitting and adjustmentManually PricedA4635NU EP UENUnderarm pad, crutch, replacement, eachPurchaseA4636NU EP UENReplacement, handgrip, cane, crutch, or walker, eachPurchaseA4637NU EP UENReplacement, tip, cane, crutch, walker, eachPurchaseA7020NU EPYInterface for cough stimulating device, includes all components, replacement onlyManually PricedA9999NUY((Unlisted Durable Medical Equipment. The manufacturers invoice must be attached to the claim form.) Misc. DME supply or accessory, not otherwise specifiedPurchaseE0100NU EP UENCane, includes canes of all materials, adjustable or fixed, with tip PurchaseE0105NU EP UENCane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tipsPurchaseE0110NU EP UENCrutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgripsPurchaseE0111NU EP UENCrutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgripPurchaseE0111NUU1NCrutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgripPurchaseE0112NU EP UENCrutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgripsPurchaseE0113NU EP UENCrutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgripPurchaseE0114NU EP UENCrutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgripsPurchaseE0116NU EP UENCrutch, underarm, other than wood, adjustable or fixed, each, with pad, tip and handgripPurchaseE0130NU EP UENWalker, rigid (pickup), adjustable or fixed heightPurchaseE0135NU EP UENWalker, folding (pickup), adjustable or fixed heightPurchaseE0140NU EPNWalker, w/trunk support, adjustable or fixed height, any typePurchaseE0141NU EP UENWalker, rigid, wheeled, adjustable or fixed heightPurchaseE0143NU EP UENWalker, folding, wheeled, adjustable or fixed heightPurchaseE0147NU EP UENWalker, heavy-duty, multiple braking system, variable wheel resistancePurchaseE0153NU EP UENPlatform attachment, forearm crutch, eachPurchaseE0154NU EP UENPlatform attachment, walker, eachPurchaseE0155NU EP UENWheel attachment, rigid pick-up walker, per pair seat attachment, walkerPurchaseE0156NU EPNSeat attachment, walkerPurchaseE0157NU EP UENCrutch attachment, walker, eachPurchaseE0158NU EP UENLeg extensions for walker, per set of four (4)PurchaseE0159NU EPNBrake attachment for wheeled walker, replacement, eachPurchaseE0160NU EP UENSitz type bath or equipment, portable, used with or without commodePurchaseE0161NU EP UENSitz type bath or equipment, portable, used with or without commode, with faucet attachment(s)PurchaseE0163NU EP UENCommode chair, stationary, with fixed armsPurchaseE0167NU EP UENPail or pan for use with commode chairPurchaseE0175NU EP UENFoot rest, for use with commode chair, eachPurchaseE0181NU EP UENPressure pad, alternating with pump, heavy-dutyCapped RentalE0182NU EP UENPump for alternating pressure padPurchaseE0184NU EP UENDry pressure mattressPurchaseE0185NU EP UENGel or gel-like pressure pad for mattress, standard mattress length and widthPurchaseE0186NU EPYAir pressure mattressPurchaseE0187NU EPYWater pressure mattressPurchaseE0189NU EP UENLambs wool sheepskin pad, any sizePurchaseE0190NU UENPositioning cushion/pillow/wedge, any shape or sizePurchaseE0190EPN( (Tumble Form Therapy Roll 4) Positioning cushion/pillow/wedge, any shape or size PurchaseE0190EPU1N( (Tumble Form Therapy Roll 6) Positioning cushion/pillow/wedge, any shape or size PurchaseE0190EPU2N( (Tumble Form Therapy Wedge 4) Positioning cushion/pillow/wedge, any shape or size PurchaseE0190EPU3N( (Tumble Form Therapy Roll 8) Positioning cushion/pillow/wedge, any shape or size PurchaseE0190EPU4N( (Tumble Form Therapy Wedge 6) Positioning cushion/pillow/wedge, any shape or size PurchaseE0190EPU5N( (Floor Sitter Wedge 4) Positioning cushion/pillow/wedge, any shape or size PurchaseE0190EPU6N( (Tumble Form Therapy Roll 12) Positioning cushion/pillow/wedge, any shape or size PurchaseE0190EPU7N( (Deluxe Wedge with strap 4) Positioning cushion/pillow/wedge, any shape or size PurchaseE0190EPU8N( (Deluxe Wedge with strap 6) Positioning cushion/pillow/wedge, any shape or size PurchaseE0190EPU9N( (Tumble Form Therapy Wedge 10) Positioning cushion/pillow/wedge, any shape or size PurchaseE0190EPKAU1N( (Tumble Form Therapy Roll 14) Positioning cushion/pillow/wedge, any shape or size PurchaseE0190EPKA U2N(Tumble Form Therapy Roll 16) Positioning cushion/pillow/wedge, any shape or size ( PurchaseE0190EPKA U3N( (Tumble Form Therapy Wedge 8) Positioning cushion/pillow/wedge, any shape or size PurchaseE0191NU EP UENHeel or elbow protector, eachPurchaseE01943NU EPY((Clinitron Bed) Air fluidized bedCapped RentalE0196NU EPNGel pressure mattressPurchaseE0197NU EP UENAir pressure pad for mattress, standard mattress length and widthPurchaseE0198NU EPYWater pressure pad for mattress, standard mattress length and widthPurchaseE0200NU EP UENHeat lamp, without stand (table model), includes bulb, or infrared elementCapped RentalE0202NU EP UENPhototherapy (bilirubin) light with photometerRental OnlyE0202UEU1NPhototherapy (bilirubin) light with photometerCapped RentalE0205NU EP UENHeat lamp, with stand includes bulb, or infrared elementCapped RentalE0217NU EP UENWater circulating heat pad with pumpCapped RentalE0225NU EP UENHydrocollator unit, includes padCapped RentalE0235NU EP UENParaffin bath unit, portable (see medical supply code A4265 for paraffin)PurchaseE0236NU EP UENPump for water circulating padCapped RentalE0239NU EP UENHydrocollator unit, portableCapped RentalE0240NU EPNBath/shower chair w/wo wheels, any sizePurchaseE0240NU EPU1 U1NBath/shower chair w/wo wheels, any sizePurchaseE0240NU EPU2 U2NBath/shower chair w/wo wheels, any sizePurchaseE0240NU EPU3 U3NBath/shower chair w/wo wheels, any sizePurchaseE0244NU EPNRaised toilet seatPurchaseE0245***NU EPU1 U1N((Bath Frame Support, Large) Tub stool or benchPurchaseE0247NU EPNTransfer bench, tub/toilet, w/wo commode openingPurchaseE0247NU EPU1 U1NTransfer bench, tub/toilet, w/wo commode openingPurchaseE0248NU EPNTransfer bench, heavy-duty, tub/toilet w/wo commode openingPurchaseE0248NU EPU1 U1NTransfer bench, heavy-duty, tub/toilet w/wo commode openingPurchaseE0249NU EP UENPad for water circulating heat unitPurchaseE0250NU EPYHYPERLINK \l "diamondexplination"(((Hospital bed, with side rails, fixed height, with mattress, purchase) Hospital bed, fixed height, with any type side rails, with mattressPurchaseE0250NU EPRR RRYHYPERLINK \l "diamondexplination"(Hospital bed, fixed height, with any type side rails, with mattressCapped RentalE0255NU EPYHYPERLINK \l "diamondexplination"(Hospital bed, variable height; hi-lo, with any type side rails, with mattress PurchaseE0255NU EPRR RRYHYPERLINK \l "diamondexplination"(Hospital bed, variable height; hi-lo, with any type side rails, with mattress Capped RentalE0255NUU1YHYPERLINK \l "diamondexplination"(((Hospital bed, with side rails, variable height; hi-lo, with mattress, purchase) Hospital bed, variable height; hi-lo, with any type side rails, with mattress PurchaseE0255UEYHYPERLINK \l "diamondexplination"(Hospital bed, variable height; hi-lo, with any type side rails, with mattressCapped RentalE0260NU EP UEYHYPERLINK \l "diamondexplination"(((Hospital bed, with side rails, semi-electric, head and foot adjustments, with mattress, purchase) Hospital bed, semi-electric, head and foot adjustment, with any type side rails with mattress PurchaseE0260NU EPRR RRYHYPERLINK \l "diamondexplination"(Hospital bed, semi-electric, head and foot adjustment, with any type side rails with mattressCapped RentalE0271NU EP UENMattress, inner springCapped RentalE0272NU EP UENMattress, foam rubberCapped RentalE0273NU EP UENBed boardPurchaseE0275NU EP UENBed pan, standard, metal or plasticPurchaseE0276NU EP UENBed pan, fracture, metal or plasticPurchaseE02773NU EPY((Low Air Loss Mattress) Powered pressure-reducing air mattressCapped RentalE0280NU EP UENBed cradle, any typePurchaseE0300EPYPediatric crib, hospital grade, fully enclosedPurchase E0300EPRRYPediatric crib, hospital grade, fully enclosedRental OnlyE0302NU EPY YHospital bed, heavy-duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattressCapped Rental E0303NU EP UEY Y YHospital bed, heavy-duty, extra wide, with weight capacity > 350 but < or = 600, any type side rails, w/mattressRental Only (Rent to Purchase)E0304NU EPY YHospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattressCapped RentalE0325NU EP UENUrinal; male, jug-type, any material PurchaseE0325NU EP UEU1 U1 U1NUrinal; male, jug-type, any material PurchaseE0326NU EP UENUrinal; female, jug-type, any materialPurchaseE0445***NU EPYHYPERLINK \l "diamondexplination"(((Pulse oximeter, including 4 disposable probes) Oximeter for measuring blood oxygen levels non-invasivelyRental OnlyE0480NU EP UENPercussor, electric or pneumatic, home modelCapped RentalE0565NU EP UEYHYPERLINK \l "diamondexplination"(Compressor, air power source for equipment which is not self-contained or cylinder drivenCapped RentalE0570NU UEYNebulizer, with compressorPurchaseE0585NU EP UENNebulizer, with compressor and heaterCapped RentalE0605NU EP UENVaporizer, room typePurchaseE0606NU EP UENPostural drainage boardCapped RentalE0607***NU EPNHome blood glucose monitorPurchaseE0621NUNSling or seat, patient lift, canvas or nylonPurchaseE0630NU EP UEYHYPERLINK \l "diamondexplination"(Patient lift, hydraulic, with seat or slingCapped RentalE0650NU EP UEYHYPERLINK \l "diamondexplination"(Pneumatic compressor, nonsegmental home modelCapped RentalE0667NU EPYHYPERLINK \l "diamondexplination"(Segmental pneumatic appliance for use with pneumatic compressor, full legCapped RentalE0668NU EPYHYPERLINK \l "diamondexplination"(Segmental pneumatic appliance for use with pneumatic compressor, full armCapped RentalE0670NU EPNSegmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunkPurchaseE0691NU EPNUltraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; treatment area two square feet or lessRental OnlyE0692NU EPNUltraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; four foot panelRental OnlyE0693NU EPNUltraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection; six foot panelRental OnlyE0694NU EPNUltraviolet multidirectional light therapy system in six foot cabinet includes bulbs/lamps, timer and eye protectionRental OnlyE0720NU EP UEYHYPERLINK \l "diamondexplination"(TENS, two lead, localized stimulationCapped RentalE0730NU EP UEY(Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulationCapped RentalE0740NU EP UENIncontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainerPurchaseE0745NU EP UEYHYPERLINK \l "diamondexplination"(Neuromuscular stimulator, electronic shock unitCapped RentalE0747NU EP UEYHYPERLINK \l "diamondexplination"(Osteogenesis stimulator, electrical noninvasive, other than spinal applicationsRental OnlyE0748NU EPYOsteogenesis stimulator, electrical noninvasive, spinal applicationsRental OnlyE0760NU EPYOsteogenesis stimulator, low intensity ultrasound, noninvasiveRental OnlyE0779NURRYHYPERLINK \l "diamondexplination"(((Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greaterRental OnlyE0840NU EP UENTraction frame, attached to headboard, cervical tractionPurchaseE0850NU EP UENTraction stand, freestanding, cervical tractionPurchaseE0860NU EP UENTraction equipment, overdoor, cervicalPurchaseE0870NU EP UENTraction frame, attached to footboard, extremity traction (e.g., Bucks)PurchaseE0880NU EP UENTraction stand, freestanding, extremity traction (e.g., Bucks)PurchaseE0890NU EP UENTraction frame, attached to footboard, pelvic tractionPurchaseE0900NU EP UENTraction stand, freestanding, pelvic traction (e.g., Bucks)PurchaseE0910NU EP UENTrapeze bars, also known as Patient Helper, attached to bed, with grab barCapped RentalE0910NURRNTrapeze bars, also known as Patient Helper, attached to bed, with grab barCapped RentalE0920NU EP UENFracture frame, attached to bed, includes weightsCapped RentalE0930NU EP UENFracture frame, freestanding, includes weightsCapped RentalE0935NU EP UEYHYPERLINK \l "diamondexplination"(Continuous passive motion exercise device for use on knee onlyCapped RentalE0940NU EP UENTrapeze bar, freestanding, complete with grab barCapped RentalE0941NU EP UENGravity assisted traction device, any typeCapped RentalE0942NU EP UENCervical head harness/halterPurchaseE0944NU EP UENPelvic belt/harness/bootPurchaseE0945NU EP UENExtremity belt/harnessPurchaseE0946NU EP UENFracture frame, dual with cross bars, attached to bed (e.g., Balken, Four Poster)PurchaseE0947NU EP UENFracture frame, attachments for complex pelvic tractionPurchaseE0948NU EP UENFracture frame, attachments for complex cervical tractionPurchaseE0950NU EP UENWheelchair accessory, tray, eachPurchaseE1036NU EPYMulti-positional patient transfer system, with integrated seat, operated by care giver; patient weight capacity up to and including 300 lbsPurchaseE1130*NU EP UEYHYPERLINK \l "diamondexplination"(Standard wheelchair, fixed full-length arms, fixed or swingaway, detachable footrestsCapped RentalE1130*NUU1YHYPERLINK \l "diamondexplination"(Standard wheelchair, fixed full-length arms, fixed or swingaway, detachable footrestsRental OnlyE1140*NU EPYHYPERLINK \l "diamondexplination"(Wheelchair, detachable arms, desk or full-length, swingaway, detachable footrestsCapped RentalE1150*NU EPYHYPERLINK \l "diamondexplination"(Wheelchair; detachable arms, desk or full-length, swingaway, detachable, elevating leg restsCapped RentalE1160*NU EPYHYPERLINK \l "diamondexplination"(Wheelchair; fixed full-length arms, swingaway, detachable, elevating leg restsCapped RentalE1224*NU EP UEYHYPERLINK \l "diamondexplination"(Wheelchair with detachable arms, elevating leg restsCapped RentalE1224*NUU1YHYPERLINK \l "diamondexplination"(((Footrests wheelchair with detachable arms, elevating leg rests) Wheelchair with detachable arms, elevating leg restsRental OnlyE1399NUNDurable medical equipment, miscellaneousManually PricedK0105NU EPNIV hanger, eachPurchaseK0606NU EPYAutomatic external defibrillator, with integrated electrocardiogram analysis, garment type (covered only for beneficiaries ages 18 and over)Capped RentalK0739NUN((DME Repair, Parts only. Repairs will not be approved for more than the allowed purchase price of new equipment. The manufacturers invoice must be attached to the repair claim for all parts.)Manually PricedK0739NUU4N((Maintenance for Capped Rental items) Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutesManually PricedK0739NU EPU1 U1N((Labor only, Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes. A maximum of twenty units per date of service is allowable, 20 units=5 hours of labor)Manually PricedK0739NU EPU3 U3N((Unlisted Repairs/Parts Only wheelchairs; applicable pages from the manufacturers catalog must be attached to the claim form. Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes.)Manually PricedS8096***NU EPN((Peak flow meter used by asthmatic patients) Portable peak flow meterPurchase Procedure codes E0250HYPERLINK \l "diamondexplination"HYPERLINK \l "diamondexplination"(, E0255HYPERLINK \l "diamondexplination"HYPERLINK \l "diamondexplination"( and E0260HYPERLINK \l "diamondexplination"HYPERLINK \l "diamondexplination"( must be billed when hospital beds are purchased for Medicaid beneficiaries of all ages. Providers must only provide these purchase-only services to beneficiaries who are expected to require the bed for a long period of time. Each procedure code for hospital beds listed above may only be billed once every 10 years. Procedure codes E0250HYPERLINK \l "diamondexplination"HYPERLINK \l "diamondexplination"(, E0255HYPERLINK \l "diamondexplination"HYPERLINK \l "diamondexplination"( and E0260HYPERLINK \l "diamondexplination"( must also be used to bill for equipment that does not meet the purchase-only criteria. They are reimbursed on a capped rental basis. The capped rental items must be used until the equipment is no longer repairable or until it is no longer appropriate for the beneficiary as verified by the physician. 242.161 Reserved1-1-10242.170 Apnea Monitors for Beneficiaries Under 1 Year of Age5-22-19Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age. Modifier UE must be used to bill for used equipment. Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a Y in the column; if not, an N is shown. Sections 212.300 and 222.200 contain information regarding specific coverage and restrictions. ( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. (() This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. National Procedure CodeM1M2DescriptionPAPayment MethodDeleted Local CodeE0619((Initial setup of Apnea monitor, includes 60 days rental) Apnea monitor, with recording featureNFirst 60 Days RentalN/AE0619EPApnea monitor, with recording featureY (on 61st day) HYPERLINK "file:///C:\\Users\\jdaily7\\Desktop\\Prosthetics%20Clean%20Up%20Update\\EPSDT-1-16-up\\Edits%20Admin\\PROSTHET-2-19-up-edit-2.doc" \l "diamondexplination" (Rental Only (Daily Rental)N/AE0619EPU1Technician and Lab Processing for setting up Pneumogram or eventNPurchaseZ1684242.180 Orthotic Appliances for Beneficiaries of All Ages8-15-18Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU. Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and older, that information is indicated with a Y in the column; if not, an N is shown. When prior authorization is not applicable (for U21) that information is shown with an N/A in the column. When codes are payable for all ages, All is indicated in the column, U21 is shown when the code is payable only for individuals under age 21 and 21+ is shown when the code is payable only for those individuals age 21 and older. ** This item is not a covered service for the diagnosis of Carpal Tunnel Syndrome prior to surgery. (() This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. This procedure code does not require prior authorization; however, the beneficiarys medical condition must fall within the following diagnosis codes. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/PROSTHET_242.180.xls"(View ICD codes.) + This item is limited to one every twelve months for beneficiaries age 21 and over. Orthotic Appliances, All Ages (Section 242.180)National Procedure CodeM1M2DescriptionAll U21 21+PA 21+Payment MethodA5500nNUFor diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe21+NPurchaseA5501nNUFor diabetics only, fitting (including follow-up) custom preparation and supply of molded from cast(s) of patient s foot (custom molded shoe), per shoe21+NPurchaseA5503nNUFor diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe21+NPurchaseA5504nNUFor diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe21+NPurchaseA5505nNUFor diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe21+NPurchaseA5506nNUFor diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe21+NPurchaseA5507NUFor diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe21+YPurchaseA5510nNUFor diabetics only, direct formed, compression molded to patient s foot without external heat source, multiple-density insert(s) prefabricated, per shoe21+NPurchaseA5512nNUFor diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient s foot, including arch, base layer minimum of inch material of shore a 35 durometer of 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each21+NPurchaseA5513nNUFor diabetics only, multiple density insert, custom molded from model of patients foot, total contact with patients foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or higher, includes arch filler and other shaping material custom fabricated, each21+NPurchaseE1810NU EPDynamic adjustable knee extension/flexion device, includes soft interface materialAllNPurchaseK0672NU EPAddition to lower extremity orthotic, removable soft interface, all components, replacement only, each. AllNPurchaseL0120NU EPCervical, flexible, nonadjustable (foam collar)AllNPurchaseL0130NU EPCervical, flexible, thermoplastic collar, molded to patientAllNPurchaseL0140NU EPCervical, semi-rigid, adjustable (plastic collar)AllNPurchaseL0150NU EPCervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)AllNPurchaseL0160NU EPCervical, semi-rigid, wire frame occipital/mandibular supportAllNPurchaseL0170NU EPCervical, collar, molded to patient modelAllNPurchaseL0172NU EPCervical, collar, semi-rigid thermoplastic foam, two pieceAllNPurchaseL0174NU EPCervical, collar, semi-rigid thermoplastic foam, two piece with thoracic extensionAllNPurchaseL0180NU EPCervical, multiple post collar, occipital/mandibular supports, adjustableAllNPurchaseL0190NU EPCervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (SOMI, Guilford, Taylor types)AllNPurchaseL0200NU EPCervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extensionAllNPurchaseL0220NU EPThoracic, rib belt, custom fabricatedAllNPurchaseL0450NU EPTLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustmentAllNPurchaseL0452NU EPTLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricatedAllNPurchaseL0454NU EPTLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustmentAllNPurchaseL0456NU EPTLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, includes fitting and adjustmentAllNPurchaseL0458NU EPTLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustmentAllYPurchaseL0460NU EPTLSO, triplanar control modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustmentAllYPurchaseL0462NU EPTLSO, triplanar control modular segmented spinal system, three rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustmentAllYPurchaseL0464NU EPTLSO, triplanar control modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustmentAllYPurchaseL0466NU EPTLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustmentAllNPurchaseL0468NU EPTLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustmentAllNPurchaseL0470NU EPTLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal and transverse planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustmentAllNPurchaseL0472NU EPTLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal) posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustmentAllNPurchaseL0480NU EPTLSO, triplanar control, one-piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricatedAllYPurchaseL0482NU EPTLSO, triplanar control, one-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricatedAllYPurchaseL0484NU EPTLSO, triplanar control, two-piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricatedAllYPurchaseL0486NU EPTLSO, triplanar control, two-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricatedAllYPurchaseL0488NU EPTLSO, triplanar control, one-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, prefabricated, includes fitting and adjustmentAllYPurchaseL0490NU EPTLSO, sagittal-coronal control, one-piece rigid plastic shell with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustmentAllYPurchaseL0621NU EPSacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustmentAllNPurchaseL0622NU EPSacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricatedAllNPurchaseL0623NU EPSacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustmentAllNPurchaseL0624NU EPSacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricatedAllNManually PricedL0625NU EPLumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustmentAllNPurchaseL0626NU EPLumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustmentAllNPurchaseL0627NU EPLumbar orthosis, sagittal control, with rigid anterior and posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustmentAllNPurchaseL0628NU EPLumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustmentAllNPurchaseL0629NU EPLumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricatedAllNManually PricedL0630NU EPLumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustmentAllNPurchaseL0631NU EPLumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustmentAllNPurchaseL0632NU EPLumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricatedAllNManually PricedL0633NU EPLumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustmentAllNPurchaseL0634NU EPLumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricatedAll NManually PricedL0635NU EPLumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustmentAllNPurchaseL0636NU EPLumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricatedAllNPurchaseL0637NU EPLumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustmentAllNPurchaseL0638NU EPLumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/ panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricatedAllNPurchaseL0639NU EPLumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustmentAllNPurchaseL0640NU EPLumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricatedAllNPurchaseL0700NU EPCervical-thoracic-lumbar-sacral orthoses (CTLSO), anterior-posterior-lateral control, molded to patient model (Minerva type)AllYPurchaseL0710NU EPCTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type)AllYPurchaseL0810NU EPHalo procedure, cervical halo incorporated into jacket vestAllYPurchaseL0820NU EPHalo procedure, cervical halo incorporated into plaster body jacketAllYPurchaseL0830NU EPHalo procedure, cervical halo incorporated into Milwaukee type orthosisAllYPurchaseL0859NU EPAddition to halo procedure, magnetic resonance image compatible system, rings and pins, any materialAll YPurchaseL0970NU EPTLSO, corset frontAllNPurchaseL0972NU EPLSO, corset frontAllNPurchaseL0974NU EPTLSO, full corsetAllNPurchaseL0976NU EPLSO, full corsetAllNPurchaseL0978NU EPAxillary crutch extensionAllNPurchaseL0980NU EPPeroneal straps, pairAllNPurchaseL0982NU EPStocking supporter grips, set of four (4)AllNPurchaseL0984NUProtective body sock, each21+NPurchaseL1000NU EPCTLSO (Milwaukee), inclusive of furnishing initial orthosis, including modelAllYPurchaseL1010NU EPAddition to CTLSO or scoliosis orthosis, axilla slingAllNPurchaseL1020NU EPAddition to CTLSO or scoliosis orthosis, kyphosis padAllNPurchaseL1025NU EPAddition to CTLSO or scoliosis orthosis, kyphosis pad, floatingAllNPurchaseL1030NU EPAddition to CTLSO or scoliosis orthosis, lumbar bolster padAllNPurchaseL1040NU EPAddition to CTLSO or scoliosis orthosis, lumbar or lumbar rib padAllNPurchaseL1050NU EPAddition to CTLSO or scoliosis orthosis, sternal padAllNPurchaseL1060NU EPAddition to CTLSO or scoliosis orthosis, thoracic padAllNPurchaseL1070NU EPAddition to CTLSO or scoliosis orthosis, trapezius slingAllNPurchaseL1080NU EPAddition to CTLSO or scoliosis orthosis, outriggerAllNPurchaseL1085NU EPAddition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensionsAllNPurchaseL1090NU EPAddition to CTLSO or scoliosis orthosis, lumbar slingAllNPurchaseL1100NU EPAddition to CTLSO or scoliosis orthosis, ring flange, plastic or leatherAllNPurchaseL1110NU EPAddition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient modelAllNPurchaseL1120NU EPAddition to CTLSO, scoliosis orthosis, cover for upright, eachAllNPurchaseL1200NU EPThoracic-lumbar-sacral-orthosis (TLSO), inclusive of furnishing initial orthosis onlyAllYPurchaseL1210NU EPAddition to TLSO (low profile), lateral thoracic extensionAllNPurchaseL1220NU EPAddition to TLSO (low profile), anterior thoracic extensionAllNPurchaseL1230NU EPAddition to TLSO (low profile), Milwaukee type superstructureAllNPurchaseL1240NU EPAddition to TLSO (low profile), lumbar derotation padAllNPurchaseL1250NU EPAddition to TLSO (low profile), anterior ASIS padAllNPurchaseL1260NU EPAddition to TLSO (low profile), anterior thoracic derotation padAllNPurchaseL1270NU EPAddition to TLSO (low profile), abdominal padAllNPurchaseL1280NU EPAddition to TLSO (low profile), rib gusset (elastic), eachAllNPurchaseL1290NU EPAddition to TLSO (low profile), lateral trochanteric padAllNPurchaseL1300NU EPOther scoliosis procedure, body jacket molded to patient modelAllYPurchaseL1310NU EPOther scoliosis procedure, post-operative body jacketAllYPurchaseL1499NU EPSpinal orthosis, not otherwise specified. ((The manufacturers invoice must be attached to all claims.)AllYManually PricedL1600NU EPHO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting and adjustmentAllNPurchaseL1610NU EPHO, abduction control of hip joints, flexible (Frejka cover only), prefabricated, includes fitting and adjustmentAllNPurchaseL1620NU EPHO, abduction control of hip joints, flexible (Pavlik harness), prefabricated, includes fitting and adjustmentAllNPurchaseL1630NU EPHO, abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricatedAllNPurchaseL1640NU EPHO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricatedAllNPurchaseL1650NU EPHO, abduction control of hip joints, static, adjustable, custom fitted (Ilfled type), prefabricated, includes fitting and adjustmentAllNPurchaseL1660NU EPHO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustmentAllNPurchaseL1680NU EPHO; abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricatedAllYPurchaseL1685NU EPHO, abduction control of hip joint, post operative hip abduction type, custom fabricatedAllYPurchaseL1686NU EPHO, abduction control of hip joint, post operative hip abduction type, prefabricated, includes fitting and adjustmentsAllYPurchaseL1690NU EPCombination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustmentAllYPurchaseL1700NU EPLegg Perthes orthosis (Toronto type), custom fabricatedAllYPurchaseL1710NU EPLegg Perthes orthosis (Newington type), custom fabricatedAllYPurchaseL1720NU EPLegg Perthes orthosis, trilateral (Tachdijan type), custom fabricatedAllYPurchaseL1730NU EPLegg Perthes orthosis (Scottish Rite type) custom fabricatedAllYPurchaseL1755NU EPLegg Perthes orthosis (Patten bottom type), custom fabricatedAllYPurchaseL1810NU EPKO, elastic with joints, prefabricated, includes fitting and adjustmentAllNPurchaseL1820NU EPKO, elastic with condylar pads and joints, prefabricated, includes fitting and adjustmentAllNPurchaseL1830NU EPKO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustmentAllNPurchaseL1832NU EPKnee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, includes fitting and adjustmentAllNPurchaseL1834NU EPKO, without knee joint, rigid, custom fabricatedAllNPurchaseL1840NU EPKO, derotation, medial-lateral, anterior cruciate ligament, custom fabricatedAllYPurchaseL1843NUKnee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment21+YPurchaseL1844NUKnee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated 21+YPurchaseL1845NU EPKnee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control with or without varus/valgus adjustment, prefabricated, includes fitting and adjustmentAllYPurchaseL1846NU EP Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control with or without varus/valgus adjustment, custom fabricatedAllYPurchaseL1847NUKnee orthosis, double upright with adjustable joint, with inflatable air support chamber(s) prefabricated, includes fitting and adjustment21+NPurchaseL1850NU EPKO, Swedish type, prefabricated, includes fitting and adjustmentAllNPurchaseL1851NU EPKnee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelfAllNPurchaseL1852NU EPKnee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelfAllYPurchaseL1860NU EPKO, modification of supracondylar prosthetic socket, custom fabricated (SK)AllYPurchaseL1900NU EPAFO, spring wire, dorsiflexion assist calf band, custom fabricatedAllNPurchaseL1902NU EPAFO, ankle gauntlet, prefabricated, includes fitting and adjustmentAllNPurchaseL1904NU EPAFO, molded ankle gauntlet, custom fabricatedAllNPurchaseL1906NU EPAFO, multiligamentus ankle support, prefabricated, includes fitting and adjustmentAllNPurchaseL1907NU EPAFO, supramalleolar with straps, with or without interface/pads, custom fabricatedAllNPurchaseL1910NU EPAFO, posterior, single bar, clasp attachment to shoe counter prefabricated, includes fitting and adjustmentAllNPurchaseL1920NU EP((Custom night A frame-KAFO, torsion control, bilateral night A frame) AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricatedAllNPurchaseL1930NU EPAFO, plastic or other material, prefabricated, includes fitting and adjustmentAllNPurchaseL1932NU EPAFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustmentAllNPurchaseL1940NU EPAFO, plastic or other material, custom-fabricatedAllNPurchaseL1945NU EPAFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricatedAllYPurchaseL1950NU EPAFO, spiral (Institute of Rehabilitative Medicine type), plastic, custom fabricatedAllNPurchaseL1951NU EPAnkle foot orthosis, spiral (Institute of Rehabilitative Medicine type), plastic, or other material, prefabricated, includes fitting and adjustmentAllNPurchaseL1960NU EPAFO, posterior solid ankle, plastic, custom fabricatedAllNPurchaseL1970NU EPAFO, plastic, with ankle joint, custom fabricatedAllNPurchaseL1980NU EPAFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar BK orthosis), custom fabricatedAllNPurchaseL1990NU EPAFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar BK orthosis), custom fabricatedAllNPurchaseL2000NU EPKAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar AK orthosis), custom fabricatedAllYPurchaseL2005NU EPKAFO, any material, single or double upright, stance control, automatic lock and swing phase release, mechanical activation, includes ankle joint, any type, custom fabricatedAllNPurchaseL2010NU EPKAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar AK orthosis), without knee joint, custom fabricatedAllYPurchaseL2020NU EPKAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar AK orthosis), custom fabricatedAllYPurchaseL2030NU EPKAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar AK orthosis), without knee joint, custom fabricatedAllYPurchaseL2035NUKnee ankle foot orthosis, full plastic, static (pediatric size) without free motion ankle, prefabricated, includes fitting and adjustment21+NPurchaseL2036NU EPKnee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricatedAllYPurchaseL2037NU EPKnee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricatedAllYPurchaseL2038NU EPKnee ankle foot orthosis, full plastic, with or without free motion knee , multi-axis ankle, custom fabricatedAllYPurchaseL2040NU EPHKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricatedAllNPurchaseL2040NU EPU1 U1((Night A frame-KAFO, torsion control, bilateral night A frame) HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricatedAllNManually Priced PurchaseL2050NU EPHKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricatedAllNPurchaseL2060NU EPHKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated AllNPurchaseL2070NU EPHKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricatedAllNPurchaseL2080NU EPHKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricatedAllNPurchaseL2090NU EPHKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricatedAllNPurchaseL2106NU EPAFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricatedAllNPurchaseL2108NU EPAFO, fracture orthosis, tibial fracture cast orthosis, custom fabricatedAllYPurchaseL2112NU EPAFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustmentAllNPurchaseL2114NU EPAFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment AllNPurchaseL2116NU EPAFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment AllNPurchaseL2126NU EPKAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricatedAllYPurchaseL2128NU EPKAFO, fracture orthosis, femoral fracture cast orthosis, custom fabricatedAllYPurchaseL2132NU EPKAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment AllYPurchaseL2134NU EPKAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid prefabricated, includes fitting and adjustmentAllYPurchaseL2136NU EPKAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment AllYPurchaseL2180NU EPAddition to lower extremity fracture orthosis, plastic shoe insert with ankle jointsAllNPurchaseL2182NU EPAddition to lower extremity fracture orthosis, drop lock knee jointAllNPurchaseL2184NU EPAddition to lower extremity fracture orthosis, limited motion knee jointAllNPurchaseL2186NU EPAddition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman typeAllNPurchaseL2188NU EPAddition to lower extremity fracture orthosis, quadrilateral brimAllNPurchaseL2190NU EPAddition to lower extremity fracture orthosis, waist beltAllNPurchaseL2192NU EPAddition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic beltAllNPurchaseL2200NU EPAdditions to lower extremity, limited ankle motion, each jointAllNPurchaseL2210NU EPAddition to lower extremity, dorsiflexion assist (plantar flexion resist), each jointAllNPurchaseL2220NU EPAddition to lower extremity, dorsiflexion and plantar flexion assist/resist, each jointAllNPurchaseL2230NU EPAddition to lower extremity, split flat caliper stirrups and plate attachmentAllNPurchaseL2232NU EPAddition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis onlyAllNManually PricedL2240NU EPAddition to lower extremity, round caliper and plate attachmentAllNPurchaseL2250NU EPAddition to lower extremity, foot plate, molded to patient model, stirrup attachmentAllNPurchaseL2260NU EPAddition to lower extremity, reinforced solid stirrup (Scott-Craig type)AllNPurchaseL2265NU EPAddition to lower extremity, long tongue stirrupAllNPurchaseL2270NU EPAddition to lower extremity, varus/valgus correction (T) strap, padded/lined or malleolus padAllNPurchaseL2275NU EPAddition to lower extremity, varus/valgus correction, plastic modification, padded/linedAllNPurchaseL2280NU EPAddition to lower extremity, molded inner bootAllNPurchaseL2300NU EPAddition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustableAllNPurchaseL2310NU EPAddition to lower extremity, abduction bar straightAllNPurchaseL2320NU EPAddition to lower extremity, nonmolded lacer, for custom fabricated orthosis onlyAllNPurchaseL2330NU EPAddition to lower extremity, lacer molded to patient model, for custom fabricated orthosis onlyAllNPurchaseL2335NU EPAddition to lower extremity, anterior swing bandAllNPurchaseL2340NU EPAddition to lower extremity, pretibial shell, molded to patient modelAllNPurchaseL2350NU EPAddition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for PTB, AFO orthoses)AllYPurchaseL2360NU EPAddition to lower extremity, extended steel shankAllNPurchaseL2370NU EPAddition to lower extremity, Patten bottomAllNPurchaseL2375NU EPAddition to lower extremity, torsion control, ankle joint and half solid stirrupAllNPurchaseL2380NU EPAddition to lower extremity, torsion control, straight knee joint, each jointAllNPurchaseL2385NU EPAddition to lower extremity, straight knee joint, heavy-duty, each jointAllNPurchaseL2390NU EPAddition to lower extremity, offset knee joint, each jointAllNPurchaseL2395NU EPAddition to lower extremity, offset knee joint, heavy-duty, each jointAllNPurchaseL2397NUAddition to lower extremity orthosis, suspension sleeve21+NPurchaseL2405NU EPAddition to knee joint, drop lock, eachAllNPurchaseL2415NU EPAddition to knee lock with integrated release mechanism , (bail, cable or equal, any material, each jointAllNPurchaseL2425NU EPAddition to knee joint, disc or dial lock for adjustable knee flexion, each jointAllNPurchaseL2430NU EPAddition to knee joint, ratchet lock for active and progressive knee extension, each jointAllNPurchaseL2492NU EPAddition to knee joint, lift loop for drop lock ringAllNPurchaseL2500NU EPAddition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ringAllNPurchaseL2510NU EPAddition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient modelAllNPurchaseL2520NU EPAddition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fittedAllNPurchaseL2525NU EPAddition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient modelAllNPurchaseL2526NU EPAddition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fittedAllNPurchaseL2530NU EPAddition to lower extremity, thigh/weight bearing, lacer, non-moldedAllNPurchaseL2540NU EPAddition to lower extremity, thigh/weight bearing, lacer, molded to patient modelAllNPurchaseL2550NU EPAddition to lower extremity, thigh/weight bearing, high roll cuffAllNPurchaseL2570NU EPAddition to lower extremity, pelvic control, hip joint, Clevis type two position joint, eachAllNPurchaseL2580NU EPAddition to lower extremity, pelvic control, pelvic slingAllNPurchaseL2600NU EPAddition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing, free, eachAllNPurchaseL2610NU EPAddition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, eachAllNPurchaseL2620NU EPAddition to lower extremity, pelvic control, hip joint, heavy-duty, eachAllNPurchaseL2622NU EPAddition to lower extremity, pelvic control, hip joint, adjustable flexion, eachAllNPurchaseL2624NU EPAddition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, eachAllNPurchaseL2627NU EPAddition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cablesAllNPurchaseL2628NU EPAddition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cablesAllNPurchaseL2630NU EPAddition to lower extremity, pelvic control, band and belt unilateralAllNPurchaseL2640NU EPAddition to lower extremity, pelvic control, band and belt bilateralAllNPurchaseL2650NU EPAddition to lower extremity, pelvic and thoracic control, gluteal pad, eachAllNPurchaseL2660NU EPAddition to lower extremity, thoracic control, thoracic bandAllNPurchaseL2670NU EPAddition to lower extremity, thoracic control, paraspinal uprightsAllNPurchaseL2680NU EPAddition to lower extremity, thoracic control, lateral support uprightsAllNPurchaseL2750NU EPAddition to lower extremity orthosis, plating chrome or nickel, per barAllNPurchaseL2755NU EP((Carbon composite ankles; addition to AFO) Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only AllNPurchaseL2760NU EPAddition to lower extremity orthosis, extension, per extension, per bar (for linear adjustment for growth)AllNPurchaseL2780NU EPAddition to lower extremity orthosis, non-corrosive finish, per barAllNPurchaseL2785NU EPAddition to lower extremity orthosis, drop lock retainer, eachAllNPurchaseL2795NU EPAddition to lower extremity orthosis, knee control, full kneecapAllNPurchaseL2800NU EPAddition to lower extremity orthosis, knee control, kneecap, medial or lateral pull, for use with custom fabricated orthosis onlyAllNPurchaseL2810NU EPAddition to lower extremity orthosis, knee control, condylar padAllNPurchaseL2810EP((Custom night A frame-KAFO, torsion control, bilateral night A frame) Addition to lower extremity orthosis, knee control, condylar padU21N/APurchaseL2820NU EPAddition to lower extremity orthosis, soft interface for molded plastic, below knee sectionAllNPurchaseL2830NU EPAddition to lower extremity orthosis, soft interface for molded plastic, above knee sectionAllNPurchaseL2840NU EPAddition to lower extremity orthosis, tibial length sock, fracture or equal, eachAllNPurchaseL2850NU EPAddition to lower extremity orthosis, femoral length sock, fracture or equal, eachAllNPurchaseL2861EPAddition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, eachU21YManually PricedL2999EPLower extremity orthoses, NOSAllNManually PricedL2999NU EP((Unlisted prosthetic devices or orthotic appliances; the manufacturers invoice must be attached to all claims.) Lower extremity orthoses, NOSAllYManually PricedL3000NU EPFoot insert, removable, molded to patient model, UCB type, Berkeley shell, eachAllNPurchaseL3002NU EPFoot insert, removable, molded to patient model, Plastazote or equal, eachAllNManually PricedL3010NU EPFoot insert, removable, molded to patient model, longitudinal arch support, eachAllNPurchaseL3020NU EPFoot insert, removable, molded to patient model, longitudinal/metatarsal support, eachAllNPurchaseL3030NU EPFoot insert, removable, formed to patient foot, each AllNPurchaseL3040NU EPFoot, arch support, removable, premolded, longitudinal, eachAllNPurchaseL3050NU EPFoot, arch support, removable, premolded, metatarsal, eachAllNPurchaseL3060NU EPFoot, arch support, removable, premolded, longitudinal/metatarsal, eachAllNPurchaseL3070NU EPFoot, arch support, non-removable, attached to shoe, longitudinal, eachAllNPurchaseL3080NU EPFoot, arch support, non-removable, attached to shoe, metatarsal, eachAllNPurchaseL3090NU EPFoot, arch support, non-removable, attached to shoe, longitudinal/metatarsal, eachAllNPurchaseL3100NU EPHallusvalgus night dynamic splintAllNPurchaseL3140NU EP UB((Bebox foot orthosis club foot abduction orthosis) Foot, abduction rotation bar, including shoesAllYPurchaseL3140NU((Don Joy knee orthosis) Foot, abduction rotation bar, including shoes21+YPurchaseL3150NU EPFoot, abduction rotation bar, without shoesAllNPurchaseL3150EPUB((Custom night A frame-KAFO, torsion control, bilateral night A frame) Foot, abduction rotation bar, without shoesU21NPurchaseL3170NU EPFoot, plastic, silicone or equal, heel stabilizer, eachAllNPurchaseL3202EPOrthopedic shoe, Oxford with supinator or pronator, childU21N/APurchaseL3204NU EP((Straight last hightop shoe, each, size 2-8) Orthopedic shoe, hightop with supinator or pronator, infantAllNPurchaseL3204NU EP U1((Straight last hightop shoe, each, size 8-12) Orthopedic shoe, hightop with supinator or pronator, infantAllNPurchaseL3204NU EP U1((Regular last hightop shoe, each, size 3-6) Orthopedic shoe, hightop with supinator or pronator, infantAllNPurchaseL3204NU EP U1((Regular last hightop shoe, each, size 8-12) Orthopedic shoe, hightop with supinator or pronator, infantAllNPurchaseL3204NU EP U1((Reverse last closed toe) Orthopedic shoe, hightop with supinator or pronator, infantAllNPurchaseL3204NU((Orthopedic shoe, hightop, normal last, each, size 3-8) Orthopedic shoe, hightop with supinator or pronator, infant21+NPurchaseL3204NU EP U1((Orthopedic shoe, hightop, normal last, each, size 8-12) Orthopedic shoe, hightop with supinator or pronator, infantAllNPurchaseL3206NU EP((Straight last hightop shoe, each, size 2-8) Orthopedic shoe, hightop with supinator or pronator, childAllNPurchaseL3206NU EP U1((Straight last hightop shoe, each, size 8-12) Orthopedic shoe, hightop with supinator or pronator, childAllNPurchaseL3206NU EP U1((Regular last hightop shoe, each, size 3-6) Orthopedic shoe, hightop with supinator or pronator, childAllNPurchaseL3206NU EP U1((Regular last hightop shoe, each, size 8-12) Orthopedic shoe, hightop with supinator or pronator, childAllNPurchaseL3206NU EP U1((Reverse last closed toe) Orthopedic shoe, hightop with supinator or pronator, childAllNPurchaseL3206NU((Orthopedic shoe, hightop, normal last, each, size 3-8) Orthopedic shoe, hightop with supinator or pronator, child21+NPurchaseL3206NU EP U1((Orthopedic shoe, hightop, normal last, each, size 8-12) Orthopedic shoe, hightop with supinator or pronator, childAllNPurchaseL3207NU EP((Straight last hightop shoe, each, size 2-8) Orthopedic shoe, hightop with supinator or pronator, juniorAllNPurchaseL3207NU EP U1((Straight last hightop shoe, each, size 8-12) Orthopedic shoe, hightop with supinator or pronator, juniorAllNPurchaseL3207NU EP U1((Regular last hightop shoe, each, size 3-6) Orthopedic shoe, hightop with supinator or pronator, juniorAllNPurchaseL3207NU EP U1((Regular last hightop shoe, each, size 8-12) Orthopedic shoe, hightop with supinator or pronator, juniorAllNPurchaseL3207NU EP U1((Reverse last closed toe) Orthopedic shoe, hightop with supinator or pronator, juniorAllNPurchaseL3207NU((Orthopedic shoe, hightop, normal last, each, size 3-8) Orthopedic shoe, hightop with supinator or pronator, junior21+NPurchaseL3207NU EP U1((Orthopedic shoe, hightop, normal last, each, size 8-12) Orthopedic shoe, hightop with supinator or pronator, juniorAllNPurchaseL3207NU EP((Orthopedic shoe, hightop, normal last, each, size 8-12) Orthopedic shoe, hightop with supinator or pronator, juniorAllNPurchaseL3208EPSurgical boot, each, infantU21N/APurchaseL3209EPSurgical boot, each, childU21N/APurchaseL3211EPSurgical boot, each, junior U21N/APurchaseL3215NU EPOrthopedic footwear, womans shoes, oxford, eachAllYPurchaseL3216NU EPOrthopedic footwear, womans shoes, depth inlay, eachAllYPurchaseL3217NU EP((Straight last hightop shoe, each, size 2-8) Orthopedic footwear, womans shoes, hightop, depth inlay, eachAllNPurchaseL3217NU EPU1 U1((Straight last hightop shoe, each, size 8-12) Orthopedic footwear, womans shoes, hightop, depth inlay, eachAllNPurchaseL3217NU EP U1((Regular last hightop shoe, each, size 3-6) Orthopedic footwear, womans shoes, hightop, depth inlay, eachAllNPurchaseL3217NU EP U1((Regular last hightop shoe, each, size 8-12) Orthopedic footwear, womans shoes, hightop, depth inlay, eachAllNPurchaseL3217NU EP U1((Reverse last closed toe) Orthopedic footwear, womans shoes, hightop, depth inlay, eachAllNPurchaseL3219NU EPOrthopedic footwear, mans shoes, oxford, eachAllYPurchase L3221NU EPOrthopedic footwear, mans shoes, depth inlay, eachAllYPurchaseL3222NU EP((Straight last hightop shoe, each, size 2-8) Orthopedic footwear, mans shoes, hightop, depth inlay, eachAllNPurchaseL3222NU EPU1 U1((Straight last hightop shoe, each, size 8-12) Orthopedic footwear, mans shoes, hightop, depth inlay, eachAllNPurchaseL3222NU EPU1 U1((Regular last hightop shoe, each, size 3-6) Orthopedic footwear, mans shoes, high-top, depth inlay, eachAllNPurchaseL3222NU EPU1 U1((Regular last hightop shoe, each, size 8-12) Orthopedic footwear, mans shoes, hightop, depth inlay, eachAllNPurchaseL3222NU EPU1 U1((Reverse last closed toe) Orthopedic footwear, mans shoes, hightop, depth inlay, eachAllNPurchaseL3224NUOrthopedic footwear, womans shoe, Oxford, used as an integral part of a brace (orthosis)21+NPurchaseL3225NUOrthopedic footwear, mans shoe, oxford, used as an integral part of a brace (orthosis)21+NPurchaseL3230NU EPOrthopedic footwear, custom shoes, depth inlay, eachAllYPurchaseL3250NU EPOrthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, eachAllYPurchaseL3253NU EPFoot, molded shoe Plastazote (or similar), custom fitted, eachAllYPurchaseL3257NU EPOrthopedic footwear, additional charge for split sizeAllYPurchaseL3260NU EPSurgical boot/shoe, eachAllNManually Priced PurchaseL3265NU EPPlastazote sandal, eachAllNPurchaseL3310NU EPLift, elevation, heel and sole, neoprene, per in.AllNPurchaseL3332NU EPLift, elevation, inside shoe, tapered, up to one-half in.AllNPurchaseL3334NU EPLift, elevation, heel, per inch AllNPurchaseL3350NU EPHeel wedgeAllNPurchaseL3360NU EPSole wedge, outside soleAllNPurchaseL3370NU EPSole wedge, between soleAllNPurchaseL3400NU EPMetatarsal bar wedge, rockerAllNPurchaseL3420NU EPFull sole and heel wedge, between soleAllNPurchaseL3450NU EPHeel, SACH cushion typeAllNPurchaseL3455NU EPHeel, new leather, standardAllNPurchaseL3465NU EPHeel, Thomas with wedgeAllNPurchaseL3540NU EPOrthopedic shoe addition, sole, fullAllNPurchaseL3580NU EPOrthopedic shoe addition, convert instep to Velcro closureAllNPurchaseL3590NU EPOrthopedic shoe addition, convert firm shoe counter to soft counterAllNPurchaseL3600NU EPTransfer of an orthosis from one shoe to another, caliper plate, existingAllNPurchaseL3620NU EPTransfer of an orthosis from one shoe to another, solid stirrup, existingAllNPurchaseL3630NU EPTransfer of an orthosis from one shoe to another, solid stirrup, newAllNPurchaseL3649NU EPU1 U1((Unlisted prosthetic devices or orthotic appliances; the manufacturers invoice must be attached to all claims.) Orthopedic shoe, modification, addition or transfer, NOSAllYManually PricedL3649EP((Orthopedic footwear, wooden sole shoe, each) Orthopedic shoe, modification, addition or transfer, NOSU21N/APurchaseL3649NU((Orthopedic footwear, wooden sole shoe, each) Orthopedic shoe, modification, addition or transfer, NOSAllNManually PricedL3650NU EPSO, figure of eight design abduction re-strainer prefabricated, includes fitting and adjustment AllNPurchaseL3660NU EPSO, figure of eight design, abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustmentAllNPurchaseL3670NU EPSO, acromio/clavicular (canvas and webbing type) prefabricated, includes fitting and adjustmentAllNPurchaseL3674NU EPShoulder orthosis, abduction positioning (airplane design), thoracic component and support bar, with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustmentAllNPurchaseL3675NUSO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting and adjustment21+NPurchaseL3710NU EPEO, elastic with metal joints, prefabricated, includes fitting and adjustmentAllNPurchaseL3720NU EPEO, double upright with forearm/arm cuffs, free motion, custom fabricatedAllNPurchaseL3730NU EPEO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricatedAllYPurchaseL3740NU EPEO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricatedAllYPurchaseL3807NU EPWHFO, without joint(s), prefabricated, includes fitting and adjustments, any typeAllNPurchaseL3808NU EPWrist-hand-finger orthotic (WHFO), rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustmentAllNPurchaseL3891EPAddition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, eachU21YManually PricedL3900NU EPWHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated AllYPurchaseL3901NU EPWHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricatedAllYPurchaseL3904NU EPWHFO, external powered, electric, custom fabricatedAllYPurchaseL3906**NU EPWrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustmentAllNPurchaseL3908NU EPWHFO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustmentAllNPurchaseL3912NU EPHFO, flexion glove with elastic finger control, prefabricated, includes fitting and adjustmentAllNPurchaseL3915+NU EPWrist, hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, includes fitting and adjustmentAllNManually PricedL3925NU EPFO, proximal interphalangeal (PIP)/distal interphalangeal (DIP), nontorsion joint/spring, extension/flexion, may include soft interface material, prefabricated, includes fitting and adjustmentAllNPurchaseL3929NU EPHFO, includes one or more nontorsion joint(s) turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustmentAllNPurchaseL3931NU EPWHFO, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustmentAllNPurchaseL3956NUAddition of joint to upper extremity orthosis, any material; per joint21+NManually PricedL3960NU EPSEWHO, abduction, positioning, airplane design, prefabricated, includes fitting and adjustmentAllYPurchaseL3962NU EPSEWHO, abduction positioning, Erbs palsy design, prefabricated, includes fitting and adjustmentAllNPurchaseL3964NU EPSEO, mobile arm supports attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustmentAllNPurchaseL3965NU EPSEO mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustmentAllYPurchaseL3966NU EPSEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustmentAllYPurchaseL3969NU EPSEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustmentAllNPurchaseL3980NU EPUpper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustmentAllNPurchaseL3982NU EPUpper extremity fracture orthosis, radius/ulnar prefabricated, includes fitting and adjustmentAllNPurchaseL3984NU EPUpper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustmentAllNPurchaseL3995NU EPAddition to upper extremity orthosis sock, fracture or equal, eachAllNPurchaseL3999NU EP((The manufacturers invoice must be attached to all claims.) Upper limb orthosis, NOSAllYManually Priced Manually PricedL4000NU EPReplace girdle for spinal orthosis (CTLSO or SO)AllYPurchaseL4002NU EPReplace strap, any orthosis, includes all components, any length, any typeAllNManually PricedL4010NU EPReplace trilateral socket brimAllNPurchaseL4020NU EPReplace quadrilateral socket brim, molded to patient modelAllNPurchaseL4030NU EPReplace quadrilateral socket brim, custom fittedAllNPurchaseL4040NU EPReplace molded thigh lacer, for custom fabricated orthosis onlyAllNPurchaseL4045NU EPReplace nonmolded thigh lacer, for custom fabricated orthosis onlyAllNPurchaseL4050NU EPReplace molded calf lacer, for custom fabricated orthosis onlyAllNPurchaseL4055NU EPReplace nonmolded calf lacer, for custom fabricated orthosis onlyAllNPurchaseL4060NU EPReplace high roll cuffAllNPurchaseL4070NU EPReplace proximal and distal upright for KAFOAllNPurchaseL4080NU EPReplace metal bands KAFO, proximal thighAllNPurchaseL4090NU EP((Custom night A frame-KAFO, torsion control, bilateral night A frame) Replace metal bands KAFO-AFO, calf or distal thighAllNPurchaseL4100NU EPReplace leather cuff KAFO, proximal thighAllNPurchaseL4110NU EPReplace leather cuff KAFO-AFO, calf or distal thighAllNPurchaseL4130NU EPReplace pretibial shellAllNPurchaseL4205NU EPRepair of orthotic device, labor component, per 15 minutesAllYPurchaseL4210NU EPRepair of orthotic device, repair or replace minor partsAllYPurchaseL4350NU EPAnkle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustmentAllNPurchaseL4360NU EPWalking boot, pneumatic with or without joints, with or without interface material, prefabricated, includes fitting and adjustmentAllNPurchaseL4370NU EPPneumatic full leg splint, prefabricated, includes fitting and adjustmentAllNPurchaseL4380NU EPPneumatic knee splint, prefabricated, includes fitting and adjustmentAllNPurchaseL4392NUReplacement soft interface material, static AFO21+NPurchaseL4394NUReplace soft interface material, foot drop splint21+NPurchaseL4396NUStatic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment21+NPurchaseL4398NUFoot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment21+NPurchaseL5999NU EP((Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturers invoice must be attached to all claims.) Lower extremity prosthesis, not otherwise specifiedAllYManually Priced Manually PricedL7499NU EP((Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturers invoice must be attached to all claims.) Upper extremity prosthesis, not otherwise specifiedAllYManually Priced Manually PricedL7510NU EP UBRepair of prosthetic device, hourly rateAllYPurchaseL7520NU EPRepair prosthetic device, labor component, per 15 minutesAllYPurchaseL8499NU EP((Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturers invoice must be attached to all claims.) Unlisted procedure for miscellaneous prosthetic servicesAllYManually Priced 242.190 Prosthetic Devices for Beneficiaries of All Ages11-1-17Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU. Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed for beneficiaries age 21 and older, that information is indicated with a Y in the column; if not, an N is shown. When codes are payable for all ages, All is indicated in the column, U21 is shown when the code is payable only for beneficiaries under age 21 and 21+ is shown when the code is payable only for those beneficiaries age 21 and older. 1 The purchase of this component is limited to one per five-year period for beneficiaries age 21 and over. * Replacement only (() This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. NOTE: Procedure codes for prosthetic eyes and information regarding prosthetic eye care is located in the Arkansas Medicaid Visual Care Program Manual. Prosthetic Devices, All Ages (Section 242.190)National Procedure CodeM1M2DescriptionAll U21 21+PA 21+Payment MethodL1499NU EP((Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturers invoice must be attached to all claims.) Spinal orthosis, not otherwise specified AllYManually Priced Manually PricedL2999NU EP((Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturers invoice must be attached to all claims.) Lower extremity orthoses, NOSAllYManually Priced Manually PricedL3649NU EPOrthopedic shoe, modification, addition or transfer, NOSAllNPurchaseL3649NU EPU1 U1((Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturers invoice must be attached to all claims.) Orthopedic shoe, modification, addition or transfer, NOSAllYManually Priced Manually PricedL3999NU EP((Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturers invoice must be attached to all claims.) Upper limb orthosis, NOSAllYManually Priced Manually PricedL4205NU EP((Orthotics and Prosthetics Repairs) Repair of orthotic device, labor component, per 15 minutesAllYManually Priced PurchaseL4210NU EP((Orthotics and Prosthetics Repairs) Repair of orthotic device, repair or replace minor partsAllYManually Priced PurchaseL4386NU EPWalking boot, nonpneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustmentAllNPurchaseL4631NU EPAnkle foot orthosis, walking boot type, varus/valgas correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricatedAllNPurchaseL5000NU EPPartial foot, shoe insert with longitudinal arch, toe fillerAllNPurchaseL5010NU EPPartial foot, molded socket, ankle height, with toe fillerAllYPurchaseL5020NU EPPartial foot, molded socket, tibial tubercle height, with toe fillerAllYPurchaseL5050NU EPAnkle, Symes, molded socket, SACH footAllYPurchaseL5060NU EPAnkle, Symes, metal frame, molded leather socket, articulated ankle/footAllYPurchaseL5100NU EPBelow knee, molded socket, shin, SACH footAllYPurchaseL5105NU EPBelow knee, plastic socket, joints and thigh lacer, SACH footAllYPurchaseL5150NU EPKnee disarticulation (or through knee), molded socket, external knee joints, shin, SACH footAllYPurchaseL5160NU EPKnee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH footAllYPurchaseL5200NU EPAbove knee, molded socket, single axis constant friction knee, shin, SACH footAllYPurchaseL5210NU EPAbove knee, short prosthesis, no knee joint (stubbies), with foot blocks, no ankle joints, eachAllYPurchaseL5220NU EPAbove knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, eachAllYPurchaseL5230NU EPAbove knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH footAllYPurchaseL5250NU EPHip disarticulation, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH footAllYPurchaseL5270NU EPHip disarticulation, tilt table type, molded socket, locking hip joint, single axis constant friction knee, shin, SACH footAllYPurchaseL5280NU EPHemipelvectomy, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH footAllYPurchaseL5301NU EPBelow knee, molded socket, shin, SACH foot, endoskeletal systemAllYPurchaseL5312NU EPKnee disarticulation (or through knee), molded socket, single axis knee, pylon, SACH foot, endoskeletal systemAllYPurchaseL5321NU EPAbove knee, molded socket, open end, SACH foot, endoskeletal system, single axis kneeAllYPurchaseL5331NU EPHip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH footAllYPurchaseL5341NU EPHemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH footAllYPurchaseL5400NU EPImmediate post-surgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below kneeAllNPurchaseL5410NU EPImmediate post-surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignmentAllNPurchaseL5420NU EPImmediate post-surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, and one cast change AK or knee disarticulationAllYPurchaseL5430NU EPImmediate post-surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension , AK or knee disarticulation, each additional cast change and realignmentAllNPurchaseL5450NU EPImmediate post-surgical or early fitting, application of nonweight bearing rigid dressing, below kneeAllNPurchaseL5460NU EPImmediate post-surgical or early fitting, application of nonweight bearing rigid dressing, above kneeAllNPurchaseL5500NU EPInitial, below knee (PTB type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, direct formedAllNPurchaseL5505NU EPInitial, above knee-knee disarticulation (ischial level socket, non-alignable system, pylon, no cover, SACH foot plaster socket, direct formedAllYPurchaseL5510NU EPPreparatory, below knee PTB type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to modelAllYPurchaseL5520NU EPPreparatory, below knee PTB type socket, non-alignable pylon, no cover, SACH foot, thermoplastic or equal, direct formedAllYPurchaseL5530NU EPPreparatory, below knee PTB type socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to modelAllYPurchaseL5535NU EPPreparatory, below knee PTB type socket, non-alignable system, pylon, no cover, SACH foot, prefabricated, adjustable open end socketAllYPurchaseL5540NU EPPreparatory, below knee PTB type socket, non alignable, pylon, no cover, SACH foot, laminated socket, molded to modelAllYPurchaseL5560NU EPPreparatory, above knee-knee disarticulation ischial level socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to modelAllYPurchaseL5570NU EPPreparatory, above knee-knee disarticulation ischial level socket, non-alignable system, pylon, no cover, SACH foot thermoplastic or equal, direct formedAllYPurchaseL5580NU EPPreparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to modelAllYPurchaseL5585NU EPPreparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, prefabricated adjustable open end socketAllYPurchaseL5590NU EPPreparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, laminated socket, molded to modelAllYPurchaseL5595NU EPPreparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient modelAllYPurchaseL5600NU EPPreparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient modelAllYPurchaseL5610NU EPAddition to lower extremity, endoskeletal system, above knee, hydracadence systemAllYPurchaseL5611NU EPAddition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4-bar linkage, with friction swing phase controlAllNPurchaseL5613NU EPAddition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4-bar linkage, with hydraulic swing phase controlAllYPurchaseL5614NUAddition to lower extremity, endoskeletal system, above knee knee disarticulation, 4-bar linkage, with pneumatic swing phase control21+YPurchaseL5616NU EPAddition to lower extremity, endoskeletal system above knee, universal multiplex system, friction swing phase controlAllYPurchaseL5617NUAddition to lower extremity, quick change self-aligning unit, above or below knee, each21+YPurchaseL5618NU EPAddition to lower extremity, test socket, SymesAllNPurchaseL5620NU EPAddition to lower extremity, test socket, below kneeAllNPurchaseL5622NU EPAddition to lower extremity, test socket, knee disarticulationAllNPurchaseL5624NU EPAddition to lower extremity, test socket, above kneeAllNPurchaseL5626NU EPAddition to lower extremity, test socket, hip disarticulationAllNPurchaseL5628NU EPAddition to lower extremity, test socket, hemipelvectomyAllNPurchaseL5629NU EPAddition to lower extremity, below knee, acrylic socketAllNPurchaseL5630NU EPAddition to lower extremity, Symes type, expandable wall socketAllNPurchaseL5631NU EPAddition to lower extremity, above knee or knee disarticulation, acrylic socketAllNPurchaseL5632NU EPAddition to lower extremity, Symes type, PTB brim design socketAllNPurchaseL5634NU EPAddition to lower extremity, Symes type posterior opening (Canadian) socketAllNPurchaseL5636NU EPAdditions to lower extremity, Symes type, medial opening socketAllNPurchaseL5637NU EPAddition to lower extremity, below knee, total contactAllNPurchaseL5638NU EPAddition to lower extremity, below knee, leather socketAllNPurchaseL5639NU EPAddition to lower extremity, below knee, wood socketAllNPurchaseL5640NU EPAddition to lower extremity, knee disarticulation, leather socketAllNPurchaseL5642NU EPAddition to lower extremity, above knee, leather socketAllNPurchaseL5643NU EPAddition to lower extremity, hip disarticulation, flexible inner socket, external frameAllYPurchaseL5644NU EPAddition to lower extremity, above knee, wood socketAllNPurchaseL5645NU EPAddition to lower extremity, below knee, flexible inner socket, external frameAllNPurchaseL5646NU EPAddition to lower extremity, below knee, air, fluid, gel or equal, cushion socketAllNPurchaseL5647NU EPAddition to lower extremity, below knee suction socketAllNPurchaseL5648NU EPAddition to lower extremity, above knee, air, fluid, gel or equal, cushion socketAllNPurchaseL5649NU EPAddition to lower extremity, ischial containment/narrow M-L socketAllYPurchaseL5650NU EPAddition to lower extremity, total contact, above knee or knee disarticulation socketAllNPurchaseL5651NU EPAddition to lower extremity, above knee, flexible inner socket, external frameAllNPurchaseL5652NU EPAddition to lower extremity, suction suspension, above knee or knee disarticulation, socketAllNPurchaseL5653NU EPAddition to lower extremity, knee disarticulation, expandable wall socketAllNPurchaseL5654NU EPAddition to lower extremity, socket insert, Symes, (Kemblo, Pelite, Aliplast, Plastazote or equal)AllNPurchaseL5655NU EPAddition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal)AllNPurchaseL5656NU EPAddition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal)AllNPurchaseL5658NU EPAddition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal)AllNPurchaseL5661NU EPAddition to lower extremity, socket insert, multi-durometer SymesAllNPurchaseL5665EPAddition to lower extremity, socket insert, multi-durometer, below kneeU21N/APurchaseL5666NU EPAdditions to lower extremity, below knee, cuff suspensionAllNPurchaseL5668NU EPAddition to lower extremity, below knee, molded distal cushionAllNPurchaseL5670NU EPAddition to lower extremity, below knee, molded supracondylar suspension (PTS or similar)AllNPurchaseL5671NU EPAddition to lower extremity, below knee/above knee, suspension locking mechanism (shuttle, lanyard or equal), excludes socket insertAllNPurchaseL5672NU EPAddition to lower extremity, below knee, removable medial brim suspensionAllNPurchaseL5673NU EPAddition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanismAllNPurchaseL5676NU EPAddition to lower extremity, below knee, knee joints, single axis, pairAllNPurchaseL5677NU EPAddition to lower extremity, below knee, knee joints, polycentric, pairAllNPurchaseL5678NU EPAddition to lower extremity, below knee, joint covers, pairAllNPurchaseL5679NU EPAddition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanismAllNPurchaseL5680NU EPAddition to lower extremity, below knee, thigh lacer, nonmoldedAllNPurchaseL5681NU EPAddition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial onlyAllNPurchaseL5682NU EPAddition to lower extremity, below knee, thigh lacer, gluteal/ischial, moldedAllNPurchaseL5683EPAddition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial onlyU21NPurchaseL5684NU EPAddition to lower extremity, below knee, fork strapAllNPurchaseL5685NU EPAddition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, eachAllNManually PricedL5686NU EPAddition to lower extremity, below knee, back check (extension control)AllNPurchaseL5688NU EPAddition to lower extremity, below knee, waist belt, webbingAllNPurchaseL5690NU EPAddition to lower extremity, below knee, waist belt, padded and linedAllNPurchaseL5692NU EPAddition to lower extremity, above knee, pelvic control belt, lightAllNPurchaseL5694NU EPAddition to lower extremity, above knee, pelvic control belt, padded and linedAllNPurchaseL5695NU EPAddition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, eachAllNPurchaseL5696NU EPAddition to lower extremity, above knee or knee disarticulation, pelvic jointAllNPurchaseL5697NU EPAddition to lower extremity, above knee or knee disarticulation, pelvic bandAllNPurchaseL5698NU EPAddition to lower extremity, above knee or knee disarticulation, Silesian bandageAllNPurchaseL5699NU EPAll lower extremity prosthesis, shoulder harnessAllNPurchaseL5700NUReplacement, socket, below knee, molded to patient model21+YPurchaseL5701NUReplacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model21+YPurchaseL5702NUReplacement, socket, hip disarticulation, including hip joint, molded to patient model21+YPurchaseL5704NU EPCustom shaped protective cover, below kneeAllNPurchaseL5705NUCustom shaped protective cover, above knee21+NPurchaseL5706NUCustom shaped protective cover, knee disarticulation21+NPurchaseL5707NUCustom shaped protective cover, hip disarticulation21+NPurchaseL5710NU EPAddition, exoskeletal knee-shin system, single axis, manual lockAllNPurchaseL5711NU EPAddition exoskeletal knee-shin system, single axis, manual lock, ultra-light materialAllNPurchaseL5712NU EPAddition exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)AllNPurchaseL5714NU EPAddition, exoskeletal knee-shin system, single axis, variable friction swing phase controlAllNPurchaseL5716NU EPAddition, exoskeletal knee-shin system, polycentric, mechanical stance phase lockAllNPurchaseL5718NU EPAddition, exoskeletal knee-shin system, polycentric, friction swing and stance phase controlAllNPurchaseL5722NU EPAddition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase controlAllNPurchaseL5724NU EPAddition, exoskeletal knee-shin system, single axis, fluid swing phase controlAllYPurchaseL5726NU EPAddition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase controlAllYPurchaseL5728NU EPAddition, exoskeletal knee-shin system, single axis, fluid swing and stance phase controlAllYPurchaseL5780NU EPAddition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase controlAllNPurchaseL5785NU EPAddition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)AllNPurchaseL5790NU EPAddition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) AllNPurchaseL5795NU EPAddition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)AllNPurchaseL5810NU EPAddition, endoskeletal knee-shin system, single axis, manual lockAllNPurchaseL5811NU EPAddition, endoskeletal knee-shin system, single axis, manual lock, ultra-light materialAllNPurchaseL5812NU EPAddition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)AllNPurchaseL5814NUAddition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock21+YPurchaseL5816NU EPAddition, endoskeletal knee-shin system, polycentric, mechanical stance phase lockAllNPurchaseL5818NU EPAddition, endoskeletal knee-shin system, polycentric, friction swing, and stance phase controlAllNPurchaseL5822NU EPAddition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase controlAllYPurchaseL5824NU EPAddition, endoskeletal knee-shin system, single axis, fluid swing phase controlAllYPurchaseL5826NUAddition, endoskeletal knee-shin system, single axis, hydraulic swing phase control with miniature high activity frame21+YPurchaseL5828NU EPAddition, endoskeletal knee-shin system, single axis, fluid swing and stance phase controlAllYPurchaseL5830NU EPAddition, endoskeletal knee-shin system, single axis, pneumatic/swing phase controlAllYPurchaseL5840NUAddition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control21+NPurchaseL5845NUAddition, endoskeletal knee-shin system, stance flexion feature, adjustable21+YPurchaseL5850NU EPAddition, endoskeletal system, above knee or hip disarticulation, knee extension assistAllNPurchaseL5855NUAddition, endoskeletal system, hip disarticulation, mechanical hip extension assist21+NPurchaseL5910NU EPAddition, endoskeletal system, below knee, alignable systemAllNPurchaseL5920NU EPAddition, endoskeletal system, above knee or hip disarticulation, alignable systemAllNPurchaseL5925NUAddition, endoskeletal system, above knee, knee disarticulation, manual lock21+NPurchaseL5930NUAddition, endoskeletal system, high activity knee control frame21+YPurchaseL5940NU EPAddition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)AllNPurchaseL5950NU EPAddition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)AllNPurchaseL5960NU EPAddition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)AllNPurchaseL5961NU EPAddition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion, and/or extension controlAllNManually PricedL5962NU EPAddition, endoskeletal system, below knee, flexible protective outer surface covering systemAllNPurchaseL5964NUAddition, endoskeletal system, above knee, flexible protective outer surface covering system21+NPurchaseL5966NUAddition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system21+NPurchaseL5968NUAddition to lower limb prostheses, multiaxial ankle with swing phase active dorsiflexion feature21+YPurchaseL5970NU EPAll lower extremity prostheses, foot, external keel, SACH footAllNPurchaseL5972NU EPAll lower extremity prostheses, flexible keel foot (SAFE, STEN, Bock Dynamic or equal)AllNPurchaseL5974NU EPAll lower extremity prostheses, foot, single axis ankle/footAllNPurchaseL5975NUAll lower extremity prosthesis, combination single axis ankle and flexible keel foot21+NPurchaseL5976NU EPAll lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)AllNPurchaseL5978NU EPAll lower extremity prostheses, foot, multiaxial ankle/foot AllNPurchaseL5979NU EPAll lower extremity prostheses, multi-axial ankle, dynamic response foot, one piece systemAllYPurchaseL5980NU EPAll lower extremity prostheses, flex-foot systemAllYPurchaseL5981NU EPAll lower extremity prostheses, flex-walk system or equalAllYPurchaseL5982NU EPAll exoskeletal lower extremity prostheses, axial rotation unitAllNPurchaseL5984NU EPAll endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustabilityAllNPurchaseL5985NUAll endoskeletal lower extremity prostheses, dynamic prosthetic pylon21+NPurchaseL5986NU EPAll lower extremity prostheses, multi-axial rotation unit (MCP or equal)AllNPurchaseL5987NUAll lower extremity prostheses, shank foot system with vertical loading pylon21+YPurchaseL5988NUAddition to lower limb prosthesis, vertical shock reducing pylon feature21+YPurchaseL5999NU EP((Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturers invoice must be attached to all claims.) Lower extremity prosthesis, not otherwise specifiedAllYManually Priced Manually PricedL6000NU EPPartial hand, Robin-Aids, thumb remaining (or equal)AllNPurchaseL6010NU EPPartial hand, Robin-Aids, little and/or ring finger remaining (or equal)AllNPurchaseL6020NU EPPartial hand, Robin-Aids, no finger remaining (or equal)AllNPurchaseL6050NU EPWrist disarticulation, molded socket, flexible elbow hinges, triceps padAllYPurchaseL6055NU EPWrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps padAllYPurchaseL6100NU EPBelow elbow, molded socket, flexible elbow hinge, triceps padAllYPurchaseL6110NU EPBelow elbow, molded socket (Muenster or Northwestern suspension types)AllYPurchaseL6120NU EPBelow elbow, molded double wall split socket, step-up hinges, half cuffAllYPurchaseL6130NU EPBelow elbow, molded double wall split socket, stump activated locking hinge, half cuffAllYPurchaseL6200NU EPElbow disarticulation, molded socket, outside locking hinge, forearmAllYPurchaseL6205NU EPElbow disarticulation, molded socket with expandable interface, outside locking hinges, forearmAllYPurchaseL6250NU EPAbove elbow, molded double wall socket, internal locking elbow, forearmAllYPurchaseL6300NU EPShoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearmAllYPurchaseL6310NU EPShoulder disarticulation, passive restoration (complete prosthesis)AllYPurchaseL6320NU EPShoulder disarticulation, passive restoration (shoulder cap only)AllYPurchaseL6350NU EPInterscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearmAllYPurchaseL6360NU EPInterscapular thoracic, passive restoration (complete prosthesis) AllYPurchaseL6370NU EPInterscapular thoracic, passive restoration (shoulder cap only)AllYPurchaseL6380NU EPImmediate post-surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbowAllNPurchaseL6382NU EPImmediate post-surgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbowAllNPurchaseL6384NU EPImmediate post-surgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular thoracicAllYPurchaseL6386NU EPImmediate post-surgical or early fitting, each additional cast change and realignmentAllNPurchaseL6388NU EPImmediate post-surgical or early fitting, application of rigid dressing onlyAllNPurchaseL6400NU EPBelow elbow, molded socket, endoskeletal system, including soft prosthetic tissue shapingAllYPurchaseL6450NU EPElbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shapingAllYPurchaseL6500NU EPAbove elbow, molded socket, endoskeletal system, including soft prosthetic tissue shapingAllYPurchaseL6550NU EPShoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shapingAllYPurchaseL6570NU EPInterscapular thoracic, molded socket, endoskeletal system including soft prosthetic tissue shapingAllYPurchaseL6580NU EPPreparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, molded to patient modelAllYPurchaseL6582NU EPPreparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, direct formedAllNPurchaseL6584NU EPPreparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover, molded to patient modelAllYPurchaseL6586NU EPPreparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover, direct formedAllYPurchaseL6588NU EPPreparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover, molded to patient modelAllYPurchaseL6590NU EPPreparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover, direct formedAllYPurchaseL6600NU EPUpper extremity additions, polycentric hinge, pairAllNPurchaseL6605NU EPUpper extremity additions, single pivot hinge, pairAllNPurchaseL6610NU EPUpper extremity additions, flexible metal hinge, pairAllNPurchaseL6615NU EPUpper extremity addition, disconnect locking wrist unitAllNPurchaseL6616NU EPUpper extremity addition, additional disconnect insert for locking wrist unit, eachAllNPurchaseL6620NU EPUpper extremity addition, flexion/extension wrist unit, with or without frictionAllNPurchaseL6623NU EPUpper extremity addition, spring assisted rotational wrist unit with latch releaseAllNPurchaseL6624NU EPUpper extremity addition, flexion/extension and rotation wrist unitAllYPurchaseL6625NU EPUpper extremity addition, rotation wrist unit with cable lockAllNPurchaseL6628NU EPUpper extremity addition, quick disconnect hook adapter, Otto Bock or equalAllNPurchaseL6629NU EPUpper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equalAllNPurchaseL6630NU EPUpper extremity addition, stainless steel, any wristAllNPurchaseL6632NU EPUpper extremity addition, latex suspension sleeve, eachAllNPurchaseL6635NU EPUpper extremity additions, lift assist for elbowAllNPurchaseL6637NU EPUpper extremity addition, nudge control elbow lockAllNPurchaseL6640NU EPUpper extremity additions, shoulder abduction joint, pairAllNPurchaseL6641NU EPUpper extremity addition, excursion amplifier, pulley typeAllNPurchaseL6642NU EPUpper extremity addition, excursion amplifier, lever typeAllNPurchaseL6645NU EPUpper extremity addition, shoulder flexion-abduction joint, eachAllNPurchaseL6650NU EPUpper extremity addition, shoulder universal joint, eachAllNPurchaseL6655NU EPUpper extremity addition, standard control cable, extraAllNPurchaseL6660NU EPUpper extremity addition, heavy-duty control cableAllNPurchaseL6665NU EPUpper extremity addition, Teflon, or equal, cable liningAllNPurchaseL6670NU EPUpper extremity addition, hook to hand cable adapterAllNPurchaseL6672NU EPUpper extremity addition, harness, chest or shoulder, saddle typeAllNPurchaseL6675NU EPUpper extremity addition, harness, (e.g., figure of eight type), single cable designAllNPurchaseL6676NU EPUpper extremity additions, harness, (e.g., figure of eight type), dual cable designAllNPurchaseL6680NU EPUpper extremity addition, test socket, wrist disarticulation or below elbowAllNPurchaseL6682NU EPUpper extremity addition, test socket, elbow disarticulation or above elbowAllNPurchaseL6684NU EPUpper extremity addition, test socket, shoulder disarticulation or interscapular thoracicAllNPurchaseL6686NU EPUpper extremity addition, suction socketAllNPurchaseL6687NU EPUpper extremity addition, frame type socket, below elbow or wrist disarticulationAllNPurchaseL6688NU EPUpper extremity addition, frame type socket, above elbow or elbow disarticulationAllNPurchaseL6689NU EPUpper extremity addition, frame type socket, shoulder disarticulationAllNPurchaseL6690NU EPUpper extremity addition, frame type socket, interscapular-thoracicAllNPurchaseL6691NU EPUpper extremity addition, removable insert, eachAllNPurchaseL6692NU EPUpper extremity addition, silicone gel insert or equal, eachAllNPurchaseL6693NUUpper extremity addition, locking elbow, forearm counterbalance21+YPurchaseL67031NU EPTerminal device, passive hand/mitt, any material, any sizeAllNPurchaseL67041NU EPTerminal device, sport/recreational/work attachment, any material, any sizeAllNPurchaseL67061NU EPTerminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlinedAllNPurchaseL67071NU EPTerminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlinedAllNPurchaseL67081NU EPTerminal device, hand, mechanical, voluntary opening, any material, any sizeAllNPurchaseL67091NU EPTerminal device, hand, mechanical, voluntary closing, any material, any sizeAllNPurchaseL6711EPTerminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric U21YPurchaseL6712EPTerminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatricU21YPurchaseL6713EPTerminal device, hand, mechanical, voluntary opening, any material, any size, pediatricU21YPurchaseL6714EPTerminal device, hand, mechanical, voluntary closing, any material, any size, pediatricU21N/APurchaseL6721NUTerminal device, hook or hand, heavy-duty, mechanical, voluntary opening, any material, any size, lined or unlined21+YPurchaseL6722NUTerminal device, hook or hand, heavy-duty, mechanical, voluntary closing, any material, any size, lined or unlined21+YPurchaseL6805NU EPTerminal device, modifier wrist flexion unitAllNPurchaseL6810NU EPTerminal device, pincher tool, Otto Bock or equalAllNPurchaseL6880NU EP Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)AllYPurchaseL6890NU EPTerminal device, gloves for above hands, production gloveAllNPurchaseL6895NU EPTerminal device, glove for above hands, custom gloveAllNPurchaseL6900NU EPHand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remainingAllNPurchaseL6905NU EPHand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remainingAllNPurchaseL6910NU EPHand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remainingAllNPurchaseL6915NU EPHand restoration (shading and measurements included), replacement glove for aboveAllNPurchaseL6920*NU EPWrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal, switch, cables, two batteries and one charger, switch control of terminal deviceAllYPurchaseL6925*NU EPWrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal deviceAllYPurchaseL6930*NU EPBelow elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal deviceAllYPurchaseL6935*NU EPBelow elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal deviceAllYPurchaseL6940*NU EPElbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal deviceAllYPurchaseL6945*NU EPElbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal deviceAllYPurchaseL6950*NU EPAbove elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal deviceAllYPurchaseL6955*NU EPAbove elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal deviceAllYPurchaseL6960*NU EPShoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal deviceAllYPurchaseL6965*NU EPShoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal deviceAllYPurchaseL6970*NU EPInterscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal deviceAllYPurchaseL6975*NU EPInterscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal deviceAllYPurchaseL70071*NU EPElectric hand, switch or myoelectric controlled, adultAllYPurchaseL70081*NU EPElectric hand, switch or myoelectric, controlled, pediatricAll YPurchaseL7009NU EPElectric hook, switch or myoelectric controlled, adultAllYPurchaseL7040*NU EPPrehensile actuator, Hosmer or equal, switch controlledAllYPurchaseL7045*NU EPElectronic hook, child, Michigan or equal, switch controlledAllYPurchaseL7170*NU EPElectronic elbow, Hosmer or equal, switch controlledAllYPurchaseL7180*NU EPElectronic elbow, Utah or equal, myoelectronically controlledAllYPurchaseL7185EPElectronic elbow, adolescent, Variety Village or equal, switch controlledU21N/APurchaseL7186EPElectronic elbow, child, Variety Village or equal, switch controlledU21N/APurchaseL7190EPElectronic elbow, adolescent, Variety Village or equal, myoelectronically controlledU21N/APurchaseL7191EPElectronic elbow, child, Variety Village or equal, myoelectronically controlledU21N/APurchaseL7260*NU EPElectronic wrist rotator, Otto Bock or equalAllYPurchaseL7261*NU EPElectronic wrist rotator, for Utah armAllYPurchaseL7360*NU EPSix volt battery, Otto Bock or equal, eachAllNPurchaseL7362*NU EPBattery charger, six volt, Otto Bock or equalAllNPurchaseL7364*NU EPTwelve volt battery, Utah or equal, eachAllNPurchaseL7366*NU EPBattery charger, twelve volt, Utah or equalAllNPurchaseL7499NU EP((Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturers invoice must be attached to all claims.) Upper extremity prosthesis, NOSAllYManually Priced Manually PricedL7510NU EP UB((Orthotics and Prosthetics Repairs) Repair of prosthetic device, repair or replace minor partsAllYManually Priced PurchaseL7510NU EP((Twister cables - repair/replace) Repair of prosthetic device, repair or replace minor partsAllNManually Priced PurchaseL7520NU EP((Orthotics and Prosthetics Repairs) Repair prosthetic device, labor component, per 15 minutesAllYManually Priced PurchaseL8000NU EPBreast prosthesis, mastectomy braAllNPurchaseL8010NU EPBreast prosthesis, mastectomy sleeveAllNPurchaseL8015NUExternal breast prosthesis garment, with mastectomy form, post-mastectomy21+NPurchaseL8020NU EPBreast prosthesis, mastectomy formAllNPurchaseL8030NU EPBreast prosthesis, silicone or equalAllNPurchaseL8031NU EPBreast prosthesis, silicone or equal, with integral adhesiveAllNPurchaseL8032NU EPNipple prosthesis, reusable, any type, eachAllNPurchaseL8300NU EPTruss, single with standard padAllNPurchaseL8310NU EPTruss, double with standard padsAllNPurchaseL8320NU EPTruss, addition to standard pad, water padAllNPurchaseL8330NU EPTruss, addition to standard pad, scrotal padAllNPurchaseL8400NU EPProsthetic sheath, below knee, eachAllNPurchaseL8410NU EPProsthetic sheath, above knee, eachAllNPurchaseL8415NU EPProsthetic sheath, upper limb, eachAllNPurchaseL8417NUProsthetic sheath/sock, including a gel cushion layer, below knee or above knee, each21+NPurchaseL8420NU EPProsthetic sock, multiple ply, below knee, eachAllNPurchaseL8430NU EPProsthetic sock, multiple ply, above knee, eachAllNPurchaseL8435NU EPProsthetic sock, multiple ply upper limb, eachAllNPurchaseL8440NU EPProsthetic shrinker, below knee, eachAllNPurchaseL8460NU EPProsthetic shrinker, above knee, eachAllNPurchaseL8465NU EPProsthetic shrinker, upper limb, eachAllNPurchaseL8470NU EPProsthetic sock, single ply, fitting below knee, eachAllNPurchaseL8480NU EPProsthetic sock, single ply fitting, above knee, eachAllNPurchaseL8485NUProsthetic sock, single ply, fitting, upper limb, each21+NPurchaseL8499NU EP((Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturers invoice must be attached to all claims.) Unlisted procedure for miscellaneous prosthetic servicesAllYManually Priced Manually PricedL8500NU EPArtificial larynx, any typeAllNPurchaseL8501NU EPTracheostomy speaking valveAllNPurchaseL8600EPImplantable breast prosthesis, silicone or equalU21NManually PricedL8605NUInjectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1ml, includes shipping and necessary supplies (covered only for ages 18 and over)18+NManually PricedL8693EPAuditory osseointegrated device abutment, any length, replacement onlyU21YManually PricedV2623NUProsthetic eye, plastic, custom21+NPurchaseV2624NUPolishing/resurfacing of ocular prosthesis21+NPurchaseV2625NUEnlargement of ocular prosthesis21+NPurchaseV2626NUReduction of ocular prosthesis21+NPurchaseV2628NUFabrication and fitting of ocular conformer21+NPurchase 242.191 Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult5-22-19Arkansas Medicaid covers wheelchairs and wheelchair seating systems for individuals ages two through adult. For any item to be covered by Arkansas Medicaid, the beneficiary must be eligible for a defined Medicaid Aid Category. Coverage is subject to the requirement that the equipment must be medically necessary for the diagnosis or treatment of an illness or injury to improve the functioning of an affected body part, and must meet all other Medicaid statutory and regulatory requirements and established criteria. The beneficiarys diagnosis must warrant the type of equipment being purchased. Items may not be covered in every instance. Providers are cautioned that an approved prior authorization does not guarantee payment. Reimbursement is contingent upon eligibility of both the beneficiary and the provider at the time service is provided and submission of an accurate and complete request. The DME provider is responsible for verifying the eligibility of the beneficiary at the time service is provided. Specialized wheelchairs and wheelchair seating systems must be ordered by a physician. For those services that are not included in the Arkansas Medicaid State Plan, (e.g., highly technological wheelchairs and rehab equipment), the PCP must complete form DMS-693, titled Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Prescription/Referral for Medically Necessary Services/Items Not Specifically Included in the Medicaid State Plan.  HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679.doc" View or print form DMS-679 and instructions for completion. NOTE: If the service or item(s) are specifically included in the Arkansas Medicaid State Plan, the completion of form DMS-693 is not required. When a request is submitted for a power wheelchair, Power-Operated Vehicle (POV) or specialized manual wheelchair, the following Medicaid requirements must be met: A. A Prescription & Prior Authorization Request for Medical Equipment form (DMS-679) must be completed and submitted. This form must not be altered by the provider.  HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679.doc" View or print form DMS-679 and instructions for completion. B. The DMS-679 must be signed and dated by the beneficiarys PCP, APRN or the ordering physician. The signature must be original. Stamp signatures are not acceptable. Medicaid will accept electronic signatures provided the electronic signatures comply with Arkansas Code 25-31-103 et seq. C. Correct Medicaid procedure codes and modifiers must be utilized. Requested items will be denied if correct procedures codes and modifiers are not used. D. All requests for prior authorization must be legible (felt pens must not be used). E. Medicaid requires the submission of the original request. F. Medical documentation from the beneficiarys PCP, APRN or ordering physician which included a detailed face-to-face medical examination must be submitted to establish medical necessity. G. An Evaluation for Wheelchair and Wheelchair Seating form (DMS-0843) must be submitted. This evaluation will be completed in three parts: 1. Part Ato be completed by the DME provider. 2. Part Bto be completed by the assistive technology practitioner or can be completed by a physical therapist or occupational therapist or seating specialist for Group 1 (one) and Group 2 (two) power wheelchairs with no power options. 3. Part Cto be completed by the beneficiarys PCP, APRN or the ordering physician. 4. An Evaluation for Wheelchair and Wheelchair Seating form (DMS-0843) must be completed for all specialized wheelchairs except for rental wheelchairs.  HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-0843.doc" View or print form DMS-0843 and instructions for completion. H. A manufacturers order form documenting the suggested retail price for the brand and model wheelchair and accessories and a manufacturers quote must be submitted with the DMS 679. I. A DMS-693, Early and Periodic Screening, Diagnosis and Treatment (EPSDT) form, must be submitted for all pediatric wheelchairs and include detailed PCP or APRN medical documentation that clearly demonstrates medical necessity and clearly identifies the medical condition and the specific equipment that will meet the beneficiarys medical needs. Form DMS-693 and the supporting documentation must be submitted as an attachment to the request for prior authorization. It will then be reviewed for medical necessity.  HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-693.doc" View or print form DMS-693. J. If requirements A through I are not completed correctly, the request could be denied. K. Arkansas Medicaid requires a Durable Medical Equipment (DME) provider to employ a RESNA (Rehabilitation Engineering and Assistive Technology Society of North America) certified ATP (Assistive Technology Practitioner) who specializes in wheelchair seating. The ATP will provide direct in-person recommendations for evaluation of the beneficiarys wheelchair selection, and is employed by the supplier. This applies for specialized manual wheelchair and power wheelchair in the category of Group 2 (single power option) and above. The ATPs involvement in the wheelchair selection must be documented. Documentation of the ATPs involvement does not qualify as a face-to-face examination and may not be cosigned by a physician. Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU. Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a Y in the column; if not, an N is shown. Other coding information found in the chart: 1 The purchase of this component for beneficiaries age 21 and older is limited to one per five-year period. 2 The purchase of this wheelchair component for beneficiaries under age 21 is limited to one per two-year period. * The purchase of wheelchairs for beneficiaries age 21 and older is limited to one per five-year period. ** Bill only for beneficiaries under age 21. # This procedure code is payable for beneficiaries ages 2 through 20. Prior authorization is required through Utilization Review. **** Items listed require prior authorization (PA) when used in combination with other items listed and the total combined value exceeds the $1,000.00 Medicaid maximum allowable reimbursement limit. ( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. Note: W/C or w/c indicates wheelchair. (() This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (Section 242.191)National Procedure CodeM1M2DescriptionPAPayment MethodE0700NU EPU1 U1Safety equipment, e.g., belt, harness or vestN****PurchaseE0700NU EPU2 U2((Travel restraint auto safe harness, EZ on vest, no known comparable product) Safety equipment, e.g., belt, harness or vestN****PurchaseE0950NU EP UE((Tray for W/C) W/C accessory, tray, eachYPurchaseE0950NU EPU2 U2((ABS tray, 4-SM 5-LG) W/C accessory, tray, eachYPurchaseE0950NU EPU3 U3((W/C Tray, Custom) W/C accessory, tray, eachYPurchaseE0950NU EPU4 U4((Tray, customized) W/C accessory, tray, eachNPurchaseE0950NU EPU5U5((Clear upper Ex support system) W/C accessory, tray, eachYPurchaseE0950NU EPU6 U6((Lap Tray Switch Array) Wheelchair accessory, tray, eachYPurchaseE0950NU EP UEU7 U7((Removable Hinged Overlay for Tray) W/C accessory, tray, eachY****PurchaseE0950NU EPU8U8((Lap Tray for Switch Array) Wheelchair accessory, tray, eachYPurchaseE0951NU EPHeel loop/holder, with or without ankle strap, eachN****PurchaseE0952NU EPToe loop/holder, eachN****PurchaseE0955NU EPWheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, eachN PurchaseE0956NU EP((Trunk supports for any W/C, other than travel, with hardware) Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, eachN****PurchaseE0956NU EPU1 U1((Lateral trunk supports, swing away, each) Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, eachN****PurchaseE0956NU EPU2 U2 ((Med. Chest Panel Support) Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, eachN****PurchaseE0956NU EPU3 U3((Chest/Thoracic Supports) Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, eachN****PurchaseE0957NU EPWheelchair accessory, medial thigh support, ((-flip-up) any type, including fixed mounting hardware, eachNPurchaseE0958NU EPManual W/C accessory, one-arm drive attachment, eachN****PurchaseE0959NU EP((Amputee adapters for conventional chair, ea.) Manual W/C accessory, adapter for amputee, eachN****PurchaseE0959NU EP ((Amputee axle plate for high performance manual W/C, ea.) Manual wheelchair accessory, adapter for amputee, eachN****PurchaseE0959NU EPU1 U1Manual W/C accessory, adapter for amputee, eachNPurchaseE0960NU EPW/C accessory, shoulder harness/straps or chest strap including any type mounting hardwareN PurchaseE0961NU EPManual W/C accessory, wheel lock brake extension (handle), eachN****PurchaseE0966NU EPManual wheelchair accessory, headrest extension, eachN****PurchaseE0967NU EP((Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, eachN****PurchaseE0967NU EPU1 U1((Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, eachN****PurchaseE0967NU EPU2 U2((Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, eachN****PurchaseE0967NU EPU3 U3((Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, eachN****PurchaseE0967NU EPU4 U4((Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, eachN****PurchaseE0970NU EPNo. 2 footplates, except for elevating legrestN****PurchaseE0971NU EPAnti-tipping device W/CN****PurchaseE0973NU EPW/C accessory, adjustable height, detachable armrest, complete assembly, eachN****PurchaseE0973NU EPU1 U1((Height Adj. Arms, replacement) W/C accessory, adjustable height, detachable armrest, complete assembly, eachN****PurchaseE0974NU EPManual wheelchair accessory, anti-rollback device (( grade aids), eachN****PurchaseE0978NU EPWheelchair accessory, positioning belt/safety belt/pelvic strap, eachN****PurchaseE0978NU EPU1 U1((Belt, safety or chest, w/pad) Wheelchair accessory, positioning belt/safety belt/ pelvic strap, eachN**** NPurchaseE0978NU EPU2 U2Wheelchair accessory, positioning belt/safety belt/pelvic strap, eachN****PurchaseE0980NU EP((Chest panel, 21-SM 22-LG) Safety vest, wheelchairN****PurchaseE0980NU EPU1 U1((Shoulder retractors) Safety vest, W/CN****PurchaseE0981NU EPW/C accessory, seat upholstery, replacement only, eachNPurchaseE0982NU EPW/C accessory, back upholstery, replacement only, eachN****PurchaseE0982NU EPU1 U1((Standard back upholstery replacement) W/C accessory, back upholstery, replacement only, eachN****PurchaseE0990NU EP((Elevating foot, leg rest) W/C accessory, elevating leg rest, complete assembly, eachN****PurchaseE0990NU EPU1 U1((Elevating Leg Rest 90 Degree, 12" - 16" Width) W/C accessory, elevating leg rest, complete assembly, eachN****PurchaseE0992NU EP( (Manual wheelchair accessory, solid seat)N****PurchaseE0992NU EPU1 U1(Manual w/c accessory, solid seat insert (Large adjustable solid seat w/hardware)N****PurchaseE0992NU EPU2 U2((Foam and Plywood Flat Side Manual wheelchair accessory, solid seat)N****PurchaseE0992NU EPU3 U3((Foam & Plywood Seat, MPI Like Manual wheelchair accessory, solid seat)N****PurchaseE0992NU EPU4 U4((Adjustable solid standard seat with hardware Manual wheelchair accessory, solid seat)N****PurchaseE0994NU EPArmrest, eachN****PurchaseE1002NU EPW/C accessory power seating system, tilt onlyY(PurchaseE1004NU EPW/C accessory, power seating system, recline only, with mechanical shear reductionY(PurchaseE1006NU EPW/C accessory, power seating system, combination tilt and recline, w/o shear reductionY PurchaseE1007NU EPWheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reductionYPurchaseE1010NU EPW/C accessory, addition to power seating system, power leg elevation system, including leg rest, eachY PurchaseE1020NU EP((Adjustable Contour Lateral Thigh Support) Residual limb support system for W/CN****PurchaseE1028NU EPWheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessoryNPurchaseE1029NU EP((Ventilator Tray With Battery Tray) Wheelchair accessory, ventilator tray, fixedYPurchaseE1030NU EPWheelchair accessory, ventilator tray, gimbaledY PurchaseE1050*NU EPFully reclining W/C, fixed full-length arms, swing-away, detachable elevating legrestsN****PurchaseE1060*NU EPFully reclining W/C, detachable arms, desk or full-length, swing-away detachable, elevating legrestsY(PurchaseE1070#EP((A maximum use of three months only) Fully-reclining wheelchair, detachable arms, (desk or full-length) swing-away, detachable footrest/elevated legrestYRental onlyE1084*NU EPHemi-W/C; detachable arms, desk or full-length, swing-away, detachable, elevating leg restsN****PurchaseE1086*NU EPHemi W/C; detachable arms, desk or full-length, swing-away, detachable footrestsN****PurchaseE1086*NU EPU1 U1Hemi W/C, detachable arms, desk or full-length, swing-away detachable footrestsYPurchaseE1088*NU EPHigh strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests Y(PurchaseE1090NU EPHigh-strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrestsN****PurchaseE1092*NU EPWide, heavy-duty W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrestsY(PurchaseE1093*NU EPWide, heavy-duty W/C; detachable arms, desk or full-length arms, swing-away, detachable footrestsY(PurchaseE1110*NU EPSemi-reclining W/C; detachable arms, desk or full-length, elevating legrestY(PurchaseE1161NU EPManual adult size W/C, includes tilt in spaceY(PurchaseE1170*NU EPAmputee W/C; fixed full-length arms, swing-away, detachable, elevating legrestsN****PurchaseE1172*NU EPAmputee W/C; detachable arms, desk or full-length, without footrests or legrestsY(PurchaseE1180*NU EPAmputee W/C; detachable arms, desk or full-length, swing-away, detachable footrestsY(PurchaseE1200*NU EPAmputee W/C; fixed full-length arms, swing-away, detachable footrestsN****PurchaseE1220*NU EPW/C, specially sized or constructed (indicate brand name, model number, if any, and justification)YManually PricedE1225NU EP((Folding Backrest, 8 Degree Bend, Low, 15" - 16") Manual W/C accessory, semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), eachN****PurchaseE1228NU EP((Folding Backrest, Tall, 19" - 20") Special back height for W/CN****PurchaseE1228NU EP((Folding Straight Backrest, Low, (15" - 16") Special back height for W/CN****PurchaseE1228NU EP((Folding Straight Backrest, Tall, 19" - 20") Special back height for W/CN****PurchaseE1228NU EPU1 U1((High back contour seat) Special back height for W/CN****PurchaseE1228NU EPU2 U2((Positioning tall back) Special back height for W/CN****PurchaseE1230*NU EPPower operated vehicle (three- or four-wheel nonhighway), specify brand name and model number Y(PurchaseE1230EP NUU1 U1Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model numberY(PurchaseE1232*EPW/C, pediatric size, tilt-in-space, folding, adjustable, with seating system Y(PurchaseE1233*EPW/C, pediatric size, tilt-in-space, rigid, adjustable, without seating systemY(PurchaseE1234*EPW/C, pediatric size, tilt-in-space, folding, adjustable, without seating systemY(PurchaseE1235*NU EPWheelchair, pediatric size, rigid, adjustable, with seating system Y(PurchaseE12352EPU1((Rigid W/C Frame) W/C, pediatric size, rigid, adjustable with seating systemYPurchaseE1236EPWheelchair, pediatric size, folding, adjustable, with seating systemYPurchaseE1237*EPW/C, pediatric size, rigid, adjustable, without seating systemY(PurchaseE1238*EPW/C, pediatric size, folding, adjustable, without seating systemY(PurchaseE1240*NU EPLightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrestY(PurchaseE1260*NU EPLightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrestsN****PurchaseE1280*NU EPHeavy-duty W/C; detachable arms, desk or full-length, elevating legrestsY(PurchaseE1290*NU EPHeavy-duty W/C; detachable arms, swing-away, detachable footrestsY(PurchaseE2201NU EP((Seat Width 20") Manual w/c accessory, nonstandard seat frame width > than or equal to 20 inches and < 24 inchesN****PurchaseE2201NU EPU1 U1((Frame Width 14"-15") Manual w/c accessory, nonstandard seat frame width>than or equal to 20 inches and <24 inchesN****PurchaseE2201NU EPU2 U2((Frame Width 19"-20") Manual w/c accessory, nonstandard seat frame width>than or equal to 20 inches and <24 inchesN****PurchaseE2201NU EPU3 U3Manual w/c accessory, nonstandard seat frame width > than or equal to 20 inches and <24 inchesN****Manually PricedE2203NU EP((Seat Depth 15") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inchesN****PurchaseE2203NU EPU1 U1((Seat Depth 17" - 18") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inchesN****PurchaseE2203NU EPU2 U2((Frame, Long; 16", 17"3, 18", 19"3, 20" Depth) Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inchesN**** PurchaseE2203NU EPU3 U3((Seat Depth 19" - 20") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inchesN****PurchaseE2203NU EPU4 U4Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inchesN Manually PricedE2206NU EPManual wheelchair accessory, wheel lock assembly, complete, eachNPurchaseE2207NU EPWheelchair accessory, crutch and cane holder, eachN****PurchaseE2208NU EPWheelchair accessory, cylinder tank carrier, eachNPurchaseE2209NU EPWheelchair accessory, arm trough, eachNPurchaseE2210NU EPWheelchair accessory, bearings, any type, replacement only, eachNPurchaseE2211NU EPManual wheelchair accessory, pneumatic propulsion tire, any size, eachNPurchaseE2212NU EPManual wheelchair accessory, tube for pneumatic propulsion tire, any size, eachNPurchaseE2213NU EPManual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, eachNPurchaseE2214NU EPManual wheelchair accessory, pneumatic caster tire, any size, eachNPurchaseE2215NU EPManual wheelchair accessory, tube for pneumatic caster tire, any size, each NPurchaseE2220NU EPManual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, eachNPurchaseE2221NU EPManual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, eachNPurchaseE2226NU EPManual wheelchair accessory, caster fork, any size, replacement only, eachNPurchaseE2231NU EPManual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardwareYPurchaseE2291EPBack, planar, for pediatric-size wheelchair, including fixed attaching hardwareNManually PricedE2292EPSeat, planar, for pediatric-size wheelchair, including fixed attaching hardwareNManually PricedE2293EPBack, contoured, for pediatric-size wheelchair, including fixed attaching hardwareNManually PricedE2294EPSeat, contoured, for pediatric-size wheelchair, including fixed attaching hardwareNManually PricedE2295EPManual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning featuresYManually PricedE2310NU EPPower w/c accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardwareYPurchaseE2311NU EPPower w/c accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardwareYPurchaseE2322NU EPPower w/c accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardwareY PurchaseE2323NU EPPower w/c accessory, specialty joystick handle for hand control interface, prefabricatedY PurchaseE2324NU EPPower w/c accessory, chin cup for chin control interfaceY PurchaseE2325NU EPPower w/c accessory, sip & puff interface nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware Y PurchaseE2326NU EPPower wheelchair accessory, breath tube kit for sip and puff interface ( (replacement only)YPurchaseE2327NU EPPower w/c accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware YPurchaseE2359NU EPPower w/c accessory, group 34 sealed lead acid battery, eachNPurchaseE2360NU EPPower w/c accessory, 22 NF non-sealed lead acid battery, eachNPurchaseE2361NU EPPower w/c accessory, 22 NF sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat) NPurchaseE2363NU EPPower w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)NPurchaseE2363NU EPU1 U1Power w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)NPurchaseE2365NU EP((U-1 gel cell battery, each) Power wheelchair accessory, U-1 sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat)NPurchaseE2365NU EPU1 U1Power w/c accessory, U-1 sealed lead acid battery, each, gel cellNPurchaseE2366NU EP((24-Volt Battery Charger - Standard, Replacement) Power w/c accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, eachNPurchaseE2367NU EP((24-Volt Battery Charger - Dual Mode, Replacement) Power w/c accessory, battery charger, dual mode, sealed or non-sealed, eachNPurchaseE2368NU EPPower wheelchair component, motor, replacement onlyNPurchaseE2369NU EPPower wheelchair component, gear box, replacement onlyNPurchaseE2370NU EPPower wheelchair component, motor and gear box combination, replacement onlyYPurchaseE2372NU EPPower wheelchair accessory, group 27 non-sealed lead acid battery, eachYPurchase E2373NU EPPower wheelchair accessory, hand or chin control interface, mini-proportional, compact, or short throw remote joystick or touchpad, proportional, including all related electronics and fixing mounting hardware.YPurchaseE2375NU EPPower wheelchair accessory, nonexpandable controller, including all related electronics and mounting hardware, replacement onlyYPurchaseE2376NU EPPower wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement onlyYPurchaseE2377NU EPPower wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issueYPurchaseE2378NU EPPower wheelchair component, actuator, replacement onlyYPurchaseE2381NU EPPower wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, eachYPurchaseE2382NU EPPower wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, eachYPurchaseE2383NU EPPower wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, eachYPurchaseE2384NU EPPower wheelchair accessory, pneumatic caster tire, any size, replacement only, eachYPurchaseE2385NU EPPower wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, eachYPurchaseE2386NU EPPower wheelchair accessory, foam filled drive wheel tire, any size, replacement only, eachYPurchaseE2387NU EPPower wheelchair accessory, foam caster tire, any size, replacement only, eachYPurchaseE2601NU EP UEGeneral use wheelchair seat cushion, width less than 22 in., any depthN****PurchaseE2602NU EP UEGeneral use wheelchair seat cushion, width 22 in. or greater, any depthNPurchaseE2611NU EP UEGeneral use wheelchair back cushion, width less than 22 in., any height, including any type mounting hardwareNPurchaseE2612NU EP UEGeneral use wheelchair back cushion, width 22 in. or greater, any height, including any type mounting hardwareNPurchaseE2619NU EPReplacement cover for wheelchair seat cushion or back cushion, eachNPurchaseE2622NU EP UESkin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depthNPurchaseE2623NU EP UESkin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depthNPurchaseE2624NU EP UESkin protection and positioning wheelchair seat cushion, adjustable width less than 22 inches, any depthNPurchaseE2625NU EP UESkin protection and positioning wheelchair seat cushion, adjustable width 22 inches or greater, any depthNPurchaseE2626NU EPWheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustableYPurchaseE2627NU EP Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable Rancho typeYPurchase E2628NU EPWheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, recliningYPurchaseE2629NU EPWheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints)YPurchaseE2630NU EPWheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension supportYPurchaseE2631NU EPWheelchair accessory, addition to mobile arm support, elevating proximal armYPurchaseE2632NU EPWheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance controlYPurchaseE2633 NU EPWheelchair accessory, addition to mobile arm support, supinatorYPurchaseK0004NU EPHigh-strength lightweight wheelchairY****PurchaseK0005*NU EP((High-performance manual W/C-adult) Ultralightweight W/CY(PurchaseK0005*NU EPU1 U1((High-performance manual W/C with growth adjustability-child) Ultralightweight W/CY(PurchaseK0010NU EP((Motorized, standard frame, DA, swing away footrests) Standard weight frame motorized/power W/CY(PurchaseK0010NU EPU1 U1((Motorized, standard frame, DA, swing away ELR) Standard weight frame motorized/power W/CY(PurchaseK0011NUEP((Motorized, power base or conventional frame w/c DA/swing away footrests, programmable electronics and custom options) Standard-weight frame motorized/power, W/C with programmable control parameters for speed adjustment, tremor dampening, acceleration control and brakingY(PurchaseK0011NU EPU1 U1((Motorized, power base or conventional frame w/c DA/swing away footrests, programmable electronics and custom options) Standard-weight frame motorized/power, W/C with programmable control parameters for speed adjustment, tremor dampening, acceleration control and brakingY(PurchaseK0012NU EP((Motorized folding frame, DA, swing away footrests) Lightweight portable motorized/power W/CY(PurchaseK0012NU EPU1 U1((Motorized folding frame, DA, swing away ELR) Lightweight portable motorized/power W/CY(PurchaseK00141,2NU EPOther motorized/ power W/C baseY(PurchaseK00141,2NU EPU1 U1((Center Drive power base) Other motorized/ power W/C baseY(PurchaseK00141,2NU EPU3 U3( (Motorized, Power Base or conventional frame W/C DA/swing away foot rests, programmable electronics and custom options) Other motorized/ power W/C baseY(PurchaseK00141,2NU EPU4 U4( (Motorized, Power Base or conventional frame W/C DA/swing away elevated foot rests, programmable electronics and custom options) Other motorized/ power W/C baseY(PurchaseK0017NU EP((Receiver for height adjustable arms) Detachable, adjustable height armrest, base, eachN****PurchaseK0017NU EPU1 U1((Dual post and adjustable height DA) Detachable, adjustable height armrest, base, eachN****PurchaseK0019NU EPArm pad, eachNPurchaseK0020NU EPFixed, adjustable height armrest, pairN****PurchaseK0038**EPU1((Knee strap) Leg strap, eachNPurchaseK0038NU EP((Single leg strap, each) Leg strap, eachN****PurchaseK0038NU EPU2 U2((Foot straps, pair) Leg strap, eachN****PurchaseK0039NU EPLeg strap, H style, eachN****PurchaseK0040NU EPAdjustable angle footplate, eachN****PurchaseK0043NU EP((SWFR, replacement) Footrest, lower extension tube, eachNPurchaseK0044NU EP((SWFR Hanger bracket, replacement) Footrest, upper hanger bracket, eachN****PurchaseK0045NU EP((Padded custom foot box) Footrest, complete assemblyN****PurchaseK0047NU EPElevating legrest, upper hanger bracket, eachN****PurchaseK0056NU EP Seat height less than 17 inches or equal to or greater than 21 inches for a high-strength, lightweight, or ultralightweight W/CN****Manually PricedK0056NU EPU1 U1((Seat height 19.5"5) Seat height less than 17 inches or equal to or greater than 21 inches for a high strength, lightweight or ultralightweight W/CN****PurchaseK0065NU EPSpoke protectors, eachN****PurchaseK0070NU EP((Wheel assembly, complete with pneumatic tires, 20/22/24/26/ea. replacement) Rear wheel assembly, complete with pneumatic tire, spokes or molded, eachN****PurchaseK0071NU EPU1 U1((Wheel assembly with pneumatic tires, 22, pair, rear wheels) Front caster assembly, complete, with pneumatic tire, eachN****PurchaseK0071NU EP ((Polyurethane casters, 5, pair, front casters) Front caster assembly, complete, with pneumatic tire, eachN****PurchaseK0072NU EP ((Polyurethane casters, 5, pair, front casters) Front caster assembly, complete, with semipneumatic tire, eachN****PurchaseK0073NU EPCaster pin lock, eachN****PurchaseK0077NU EPFront caster assembly, complete, with solid tire, eachNPurchaseK0108NU EP((W/C miscellaneous equipment; applicable pages from the manufacturers catalog must be attached to the claim form.) Other accessoriesYManually PricedK0739NU EPU1 U1((Labor only, Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes. A maximum of twenty units per date of service is allowable, 20 units=5 hours of labor)YPurchaseS1002EP((Wheelchair, custom molded seating system only) Customized item, list in addition to code for basic itemN****Manually PricedS1002NU EPU1 U1((Foam-in-place seat, Pindot quick foam contour system) Customized item, list in addition to code for basic itemN****Purchase The following procedure codes may only be billed on paper. Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (Section 242.191)National Procedure CodeM1M2DescriptionPAPayment MethodDeleted Local CodeE0190EPUA((Adductor - no hardware)N****PurchaseZ2140E0190NUUA((Adductor - no hardware)N****PurchaseZ2140E0190EPUB((Abductor - no hardware)N****PurchaseZ2141E0190NUUB((Abductor - no hardware)N****PurchaseZ2141E0190EPUC((Hip guides - no hardware)NPurchaseZ2142E0190NUUC((Hip guides - no hardware)NPurchaseZ2142E0190EPUD((Laterals - no hardware)N****PurchaseZ2145E0190NUUD((Laterals - no hardware)N****PurchaseZ2145E0191EPU1((Elbow Block w/Bracket)N****PurchaseZ2203E0191NUU1((Elbow Block w/Bracket)N****PurchaseZ2203E0700EPU3PC Car Seat/Snug SeatYPurchaseZ1824**E0951 E0952EPHeel loop/holder, any type, with or without ankle strap, (ea) Shoe Holders S/M/L/XLN****PurchaseZ2183E0951 E0952NUHeel loop/holder, any type, with or without ankle strap, (ea) Shoe Holders S/M/L/XLN****PurchaseZ2183E0955EPSub Occipital Three Piece Head Set w/REM HardwareN****PurchaseZ2188E0955NUSub Occipital Three Piece Head Set w/REM HardwareN****PurchaseZ2188E0956EPU4((Lateral Hip/Thigh support w/hardware (ea))N****PurchaseZ2139E0956NUU4((Lateral Hip/Thigh support w/hardware (ea))N****PurchaseZ2139E0956EPU5((Rigid Side Guard)N****PurchaseZ2186E0956NUU5((Rigid Side Guard)N****PurchaseZ2186E0956EPU6((Fabric Side Guard)N****PurchaseZ2187E0956NUU6((Fabric Side Guard)N****PurchaseZ2187E0957EPU1((Adjustable Rem. Abductor w/hardware (ea))N****PurchaseZ2137E0957NUU1((Adjustable Rem. Abductor w/hardware (ea))N****PurchaseZ2137E0957EPU2((Adjustable Flip Down Abductor w/hardware (ea))N****PurchaseZ2138E0957NUU2((Adjustable Flip Down Abductor w/hardware (ea))N****PurchaseZ2138E0970EPSWFR Composite Foot Plate (Replacement)N****PurchaseZ2181E0970NUSWFR Composite Foot Plate (Replacement)N****PurchaseZ2181E0978EPU3((Forehead Strap System)N****PurchaseZ2189E0978NUU3((Forehead Strap System)N****PurchaseZ2189E1011EPRigid Wheelchair Growth Kit Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)NPurchaseZ2185E1011NURigid Wheelchair Growth Kit Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)NPurchaseZ2185E1020EPU1((Adjustable Contour Lateral Pelvic Support)N****PurchaseZ2589E1020NUU1((Adjustable Contour Lateral Pelvic Support)N****PurchaseZ2589E1028EPWheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory, Swing Away Mount (Joystick)N****PurchaseZ2616E1028NUWheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory, Swing Away Mount (Joystick)N****PurchaseZ2616E2201EPU3X-Tube Assembly Folding W/C (Replacement)N****PurchaseZ2184E2201EPManual W/C Accessory, Non-standard Seat Frame Width, > or equal to 20 & <24N****PurchaseZ2184E2201NUManual W/C Accessory, Non-standard Seat Frame Width, > or equal to 20 & <24N****PurchaseZ2184E2201EPU1Manual W/C Accessory, Non-standard Seat Frame Width, > or equal to 24 & <27N****PurchaseZ2184E2201NUU1Manual W/C Accessory, Non-standard Seat Frame Width, > or equal to 24 & <27N****PurchaseZ2184E2201EPU2Manual W/C Accessory, Non-standard Seat Frame Width, > or equal to 24 & <27N****PurchaseZ2184E2201NUU1Manual W/C Accessory, Non-standard Seat Frame Depth, 22 to 25N****PurchaseZ2184E2203EPManual W/C Accessory, Non-standard Seat Frame Depth 20 to <22N****PurchaseZ2184E2203EPU1Manual W/C Accessory, Non-standard Seat Frame Depth, 22 to 25N****PurchaseZ2184E2203NUManual W/C Accessory, Non-standard Seat Frame Depth, > or equal to 20 & 24N****PurchaseZ2184E2210NU EPPower W/C Sleeve Top or Bottom Stem Bearing (Replacement)N****PurchaseZ2175E2231NU EPU1((Growing Seat Pan)N****PurchaseZ2585E2373NU EPU1((Remote Joystick Module)N****PurchaseZ2592E2611 NU EPGeneral use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware, Growing Back UpholsteryN****PurchaseZ2586E2611NU EPU1((Adjustable Back Upholstery)N****PurchaseZ2604E2612NU EPGeneral use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardwareN****PurchaseZ2586E2619NU EPAir Exchange Seat Cover for Cushions (Replacement)NPurchaseZ2158E2620NU EPU1((Deep Contour Back 20" Width)N****PurchaseZ2588E2622NU EPU1Fluid Flo-lite pad (Replacement)NPurchaseZ2159K0045NU EPOne-piece footboard (each)N****PurchaseZ1613K0045NU EPU2Custom foot platformN****PurchaseZ1793K0108NU EPU4((Swing Away Adj. Stroller Handles)YPurchaseZ2196K0108NU EPU2((Quick Release Axle)YPurchaseZ2582K0108NU EPU3((Transit Option)YPurchaseZ2599 Required Documentation Face-to-Face Examination In order for Medicaid to provide reimbursement for a Power/motorized Wheelchair (PWC), Power Operated Vehicle (POV) (scooter) or specialized manual wheelchair, the following requirements must be met. A. A face-to-face physician examination must be performed. B. The physician must perform a medical examination for the specific purpose of assessing the beneficiarys mobility limitation and needs. The results of this exam must be recorded in the patients medical record. C. The prescription must be written only after the face-to-face physician examination and assessment of mobility limitations have occurred and the medical history and physical examination is completed. D. The prescription and the medical records documenting the in-person visit and examination report must be sent to the equipment supplier within forty-five (45) days of completion of the examination. E. The physician may refer the beneficiary to a licensed/certified professional, a Physical Therapist (PT) or Occupational Therapist (OT) to perform a wheelchair assessment. If the beneficiary is referred to a physical/occupational therapist before the physician completes the face-to-face examination, the physician must review the physical/occupational therapists written report and perform the final examination. The forty-five (45)-day period begins on the date of the physicians final face-to-face examination and must be submitted with the prior authorization request. The face-to-face examination must include: History of the present condition(s) and past medical history that is relevant to mobility needs: 1. Symptoms that limit ambulation. 2. Diagnoses that are responsible for these symptoms. 3. Medications or other treatment for these symptoms. 4. Progression of ambulation difficulty over time. 5. Other diagnoses that may relate to ambulatory problems. 6. How far the patient can walk without stopping. 7. What ambulatory assistance (cane, walker, wheelchair, caregiver) is currently being used. 8. What has changed to now require use of a power mobility device. 9. Ability to stand up from a seated position without assistance. Physical examination that is relevant to mobility needs: 1. Beneficiarys weight and height. 2. Cardiopulmonary examination. 3. Musculoskeletal examination, arm and leg strength and range of motion. 4. Neurological examination, gait, balance and coordination. The examination should be tailored to the individual patients condition. The history should clearly establish the patients functional abilities and limitations related to mobility and ambulation. In addition to all other requirements, a power mobility device is covered by Medicaid only if the beneficiary has a mobility limitation that significantly impairs his/her ability to perform activities of daily living within the home. Provider-created forms and letters are not a substitute for other required forms and will not be considered. Additional Wheelchair Documentation A. The purchase of a wheelchair for individuals twenty-one (21) years of age and over is limited to one wheelchair per five (5)-year period if medically necessary. A wheelchair is a dependable mobility base with positioning components. It has complex positioning capabilities and is designed to grow in width, depth and height to accommodate physical changes of its users, it is of use to people with certain medical conditions and serves a specific medical purpose related to the condition of the patient. B. The purchase of a wheelchair for an individual twenty (20) years of age and under is limited to one per two (2)-year period, if medically necessary. C. Payment is made for one wheelchair only as stipulated in A. and B. Backup and loaner D. wheelchairs are not covered by Arkansas Medicaid. D. Requests for a wheelchair that is beneficial primarily in allowing the beneficiary to perform leisure or recreational activities only will be denied. It is not medical in nature. Wheelchairs are authorized for medical use only. E. Strollers and stroller-like chairs of any kind are not covered by Arkansas Medicaid. A stroller is a four-wheeled, often collapsible, chair-like carriage. They are helpful to caregivers and are typically used for transportation. Although stroller and stroller-like chairs may be used to transport individuals with medical conditions, such items do not serve a medical purpose. Strollers and stroller-like chairs have no positioning components for medical use, cannot be modified for growth and accommodate changes in medical or physical condition, and cannot be self-propelled by the individual. F. Prior authorization is required even when insurance pays primary to Medicaid. Explanation of benefits (EOB) of the other insurance must be submitted with the request. G. All wheelchair requests require a manufacturers brand and the model name of the base. H. In the event a wheelchair is stolen, damaged in the home, or by vehicle or fire, a police/fire report, copy of the home owners/auto insurance coverage and detailed documentation of events leading to the loss/damage are required. I. Mobility bases for car seats are not covered by Medicaid. J. Options, accessories, and replacement parts that are medically necessary for wheelchairs that do not have specific HCPCS codes should be coded K0108 (other accessories). The manufacturers suggested retail price (MSRP) must be listed for each item coded K0108, and the MSRP quote to the DME provider must be included. The MSRP quote must not be altered by the DME provider. If the MSRP is altered in any way, the request will be denied. K. In the event a beneficiary wishes to change services from one DME provider to another DME provider, an affidavit signed and dated by the beneficiary must be submitted with the request from the new DME provider. L. The existence of a procedure code does not necessarily indicate coverage by Arkansas Medicaid. M. The allowed amount of a POV includes all options and accessories that are provided at the time of initial issue. This includes but is not limited to batteries, battery chargers, seating systems, etc. All options and accessories provided at the initial issue of a Power-Operated Vehicle (POV) are included and should not be billed separately. N. If coverage criteria is not met for a specific item requested, and Arkansas Medicaid determines that another item is more appropriate and meets medical necessity, that item will be authorized. O. The wheelchair will significantly improve the beneficiarys ability to participate in Mobility Related Activities of Daily Living (MRADL) and the individual will use the wheelchair on a regular basis in the home. P. The individuals home will provide adequate access between rooms, maneuvering space and surface for use of the requested wheelchair. Non-Covered Items for Specialized Wheelchairs and Wheelchair Systems A. Items that are deluxe in nature. Deluxe items are items of convenience that are not medically necessary. Deluxe items are often used for social purposes or convenience. Deluxe items include deluxe accessories which increase the cost of purchase or operation. Deluxe items and deluxe accessories are not covered by Arkansas Medicaid. B. Items for use in hospitals, nursing home or other institutions. C. Items for the beneficiarys comfort or the caregivers convenience. D. Two pieces of equipment that serve the same purpose. E. Backup and loaner wheelchairs. F. Wheelchairs that primarily allow the beneficiary to perform leisure or recreational activities. G. Mobility bases for car seats. H. Items that are not primarily used in the treatment of a disease, injury or illness. I. Any items or item upgrades that add cost without improving the beneficiarys ability to perform Mobility Related Activities of Daily Living. Warranty, Maintenance and Replacement of Specialized Wheelchairs and Wheelchair Systems All standard durable medical equipment must have a manufacturers warranty. If a DME provider supplies equipment that is not covered under a warranty, the provider is responsible for repairs, adjustments, replacements and maintenance. The warranty begins on the date of delivery (date of service) to the beneficiary. The DME provider must keep a copy of the warranty for audit review by Medicaid. Medicaid may request a copy of the warranty. DME suppliers must furnish at least a minimum of six (6) months warranty for any adjustments to new wheelchairs at no charge. Labor will not be covered for the initial chair and for parts and services that are under warranty. 242.192 Specialized Rehabilitative Equipment for Beneficiaries of All Ages5-22-19Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU. Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a Y in the column; if not, an N is shown. ** Indicates that providers may bill only for beneficiaries under age 21. ( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. (() This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. Specialized Rehabilitative Equipment, All Ages (Section 242.192)National Procedure CodeM1M2DescriptionPAPayment MethodA8000NU EPHelmet, protective, soft, prefabricated, includes all components and accessoriesNPurchaseA8001NU EPHelmet, protective, hard, prefabricated, includes all components and accessoriesNPurchaseA8002NU EPHelmet, protective, soft, custom fabricated, includes all components and accessoriesNPurchaseA8003NU EPHelmet, protective, hard, custom fabricated, includes all components and accessoriesNPurchaseE0149NU EP((4 Wheel Reverse Walker) Walker, heavy-duty, wheeled, rigid or folding, any typeNPurchaseE0163EP NUU1 U1((Potty Chair - Small) Commode chair, stationary, with fixed armsYPurchaseE0168EP((Rehab Shower/Commode Chair) Commode chair, extra wide and/or heavy-duty, stationary or mobile, with or without arms, any type, eachY(PurchaseE0168EPUB((Adaptive Commode Chair) Commode chair, extra wide and/or heavy-duty, stationary or mobile, with or without arms, any type, eachNPurchaseE0168NU((Adaptive Commode Chair) Commode chair, extra wide and/or heavy-duty, stationary or mobile, with or without arms, any type, eachNPurchaseE0168NUU1((Rehab Shower/Commode Chair) Commode chair, extra wide and/or heavy-duty, stationary or mobile, with or without arms, any type, eachY(PurchaseE0241NU EP((Bolt-on Sm. Grab Bar) Bathroom wall rail, eachNPurchaseE0241NU EPU1 U1((Bolt-on Lg. Grab Bar) Bathroom wall rail, eachNPurchaseE0241NU EPU2 U2((Bolt-on Med. Grab Bar) Bathroom wall rail, eachNPurchaseE0245NU EP((Adj. Bath Chair w/Back) Tub stool or benchNPurchaseE0245NU EPU2 U2((Padded Tub Transfer Bench) Tub stool or benchNPurchaseE0245NU EPU3 U3((30 Bath Chair) Tub stool or benchNPurchaseE0245NU EPU4 U4((38 Bath Chair) Tub stool or benchNPurchaseE0245NU EPU5 U5((47 Bath Chair) Tub stool or benchNPurchaseE0245NU EPU6 U6((56 Bath Chair) Tub stool or benchNPurchaseE0245NU EPUB UB((Non-padded tub transfer bench) Tub stool or benchNPurchaseE0246NU EP((Clamp-on Tub Grab Bar) Transfer tub rail attachmentNPurchaseE0637NU EPCombination sit-to-stand frame/table system, any size, including pediatric, with seat lift feature, with or without wheelsYPurchaseE0638NU EPStanding frame system, any size, with or without wheelsYPurchaseE0638EP EPU1 U2Standing frame system, any size, with or without wheelsYPurchaseE0700NU EP((Chin Guard for Safety Helmet, Sm.) Safety equipment, e.g., belt, harness or vestNPurchaseE0705NU EPTransfer device, any type, each YPurchaseE0911NU EPTrapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar NCapped RentalE0950NU EPU1 U1((Tray for gait trainer) Wheelchair accessory, tray, eachNPurchaseE1031**EP((Transition Toddler Chair - Sm.) Rollabout chair, any and all types with casters five inches or greaterNPurchaseE1031**EPU1((Corner Chair w/Tray & Casters - Sm.) Rollabout chair, any and all types with casters five inches or greaterNPurchaseE1031**EPU2((Transition Toddler Chair Lg.) Rollabout chair, any and all types with casters five inches or greaterYPurchaseE1031**EPU3((Corner Chair w/Tray & Casters - Lg.) Rollabout chair, any and all types with casters five inches or greaterNPurchaseE1031**EPU4((Bolster Chair w/Tray, Chest Support & Casters - Sm.) Rollabout chair, any and all types with casters five inches or greaterNPurchaseE1031**EPU5((Low Back Activity Chair) Rollabout chair, any and all types with casters five inches or greaterYPurchaseE1035**EP((Carrie Seat - Preschool) Multi-positional patient transfer system, with integrated seat, operated by care giverYPurchaseE1035**EPU1((Carrie Seat - Elementary) Multi-positional patient transfer system, with integrated seat, operated by care giverYPurchaseE1035**EPU2((Carrie Seat - Jr.) Multi-positional patient transfer system, with integrated seat, operated by care giverYPurchaseE1035NU EPU3 U3((Carrie Seat - Sm. Adult) Multi-positional patient transfer system, with integrated seat, operated by care giverY(PurchaseE8000EP((14) Gait trainer, pediatric size, posterior support, includes all accessories and componentsYPurchaseE8000EPU1((19) Gait trainer, pediatric size, posterior support, includes all accessories and componentsYPurchaseE8000EPU2((Intermediate) Gait trainer, pediatric size, posterior support, includes all accessories and componentsYPurchaseE8001EP((14) Gait trainer, pediatric size, upright support, includes all accessories and componentsYPurchaseE8001EPU1((19) Gait trainer, pediatric size, upright support, includes all accessories and componentsYPurchaseE8001EPU2((Intermediate) Gait trainer, pediatric size, upright support, includes all accessories and componentsYPurchaseE8002EP((14) Gait trainer, pediatric size, anterior support, includes all accessories and componentsYPurchaseE8002EPU1((19) Gait trainer, pediatric size, anterior support, includes all accessories and componentsYPurchaseE8002EPU2((Intermediate) Gait trainer, pediatric size, anterior support, includes all accessories and componentsYPurchase The following list of codes may only be billed on paper. Specialized Rehabilitative Equipment, All Ages (Section 242.192)National Procedure CodeM1M2DescriptionPAPayment MethodDeleted Local CodeA9300EPU3((Therapy Ball - Sm.)NPurchaseZ2038**A9300EPU1((Therapy Ball - Med.)NPurchaseZ2039**A9300EPU2((Therapy Ball - Lg.)NPurchaseZ2040**E0143EPU1((Tyke Strider Walker w/2 Wheels)NPurchaseZ2094**E0143EPU2((Tweener Strider Walker w/2 Wheels)NPurchaseZ2095**E0143EPU2((Middle Strider Walker w/2 Wheels)NPurchaseZ2096**E0143EPU4((Adult Strider Walker w/2 Wheels)NPurchaseZ2097E0143NUU4((Adult Strider Walker w/2 Wheels)NPurchaseZ2097E0149EP4 Wheel Reverse WalkerNPurchaseZ2099 Z2100 Z2101 Z2102E0149NU4 Wheel Reverse WalkerNPurchaseZ2099 Z2100 Z2101 Z2102E0149EPU1((4 Wheel Front Swivel Reverse Walker)NPurchaseZ2104E0149NUU1((4 Wheel Front Swivel Reverse Walker)NPurchaseZ2104E0149EP((4 Wheel Front Swivel Reverse Walker)NPurchaseZ2105E0149NUU2((4 Wheel Front Swivel Reverse Walker)NPurchaseZ2105E0149EPU3((4 Wheel Front Swivel Reverse Walker)NPurchaseZ2106E0149NUU3((4 Wheel Front Swivel Reverse Walker)NPurchaseZ2106E0149EPU4((4 Wheel Front Swivel Reverse Walker)NPurchaseZ2107E0149NUU4((4 Wheel Front Swivel Reverse Walker)NPurchaseZ2107E0168EPU2((Lg. Toilet Support w/Hi Back)NPurchaseZ2074E0168NUU2((Lg. Toilet Support w/Hi Back)NPurchaseZ2074E0168EPU3((Sm. Toilet Support w/Hi Back)NPurchaseZ2075E0168NUU3((Sm. Toilet Support w/Hi Back)NPurchaseZ2075E0190EPU5((48 Side Lyer)NPurchaseZ2015**E0190KAU5((48 Side Lver)NPurchaseZ2015**E0190EPU6((72 Side Lyer)NPurchaseZ2016**E0190KAU6((72 Side Lver)NPurchaseZ2016**E0190EPAdj. Abduction Wedge w/hip stabilizerNPurchaseZ2002E0190NUAdj. Abduction Wedge w/hip stabilizerNPurchaseZ2002E0190KAU4Adj. Abduction Wedge w/hip stabilizerNPurchaseZ2002E0240EPU4((Bath Chair Headrest)NPurchaseZ2239E0240NUU4((Bath Chair Headrest)NPurchaseZ2239E0244EPU1((Toilet Seat Reducer Ring (Padded))NPurchaseZ2089E0244NUU1((Toilet Seat Reducer Ring (Padded))NPurchaseZ2089E0245EPU7((Lg. Wrap Around Bath Support)NPurchaseZ2072E0245NUU7((Lg. Wrap Around Bath Support)NPurchaseZ2072E0245EPU8((Sm. Wrap Around Back Support)NPurchaseZ2073E0245NUU8((Sm. Wrap Around Back Support)NPurchaseZ2073E0246EPU1Diverter Valve for Handheld ShowerNPurchaseZ2605E0246NUU1Diverter Valve for Handheld ShowerNPurchaseZ2605E0246EPU2((Flexible Shower Hose)NPurchaseZ2077E0246NUU2((Flexible Shower Hose)NPurchaseZ2077E0638EPU3((Sm. 51 Supine Stander)Y(PurchaseZ1996E0638NUU3((Sm. 51 Supine Stander)Y(PurchaseZ1996E0638EPU4((Lg. 71 Supine Stander)Y(PurchaseZ1997E0638NUU4((Lg. 71 Supine Stander)Y(PurchaseZ1997E0638EPU5((27 Prone Stander)YPurchaseZ1998**E0638EPU6((35 Prone Stander)YPurchaseZ1999**E0638EPU7((42 Prone Stander)Y(PurchaseZ2000**E0638EPU8((50 Prone Stander)Y(PurchaseZ2001E0638NUU8((50 Prone Stander)Y(PurchaseZ2001E0638EPUA((Up Rite Stander - Sm.)YPurchaseZ2006**E0638EPUB((Up Rite Stander - Med.)YPurchaseZ2007**E0638EPUA U1((Up Rite Stander - Lg.)YPurchaseZ2008E0638NUUA U1((Up Rite Stander - Lg.)YPurchaseZ2008E0641EPU2((Tumble Form Tri Stander w/Tray - Sm.)Y(PurchaseZ2012**E0641EPU1((Tumble Form Tri Stander w/Tray - Lg.)Y(PurchaseZ2013**E0700EPU4((Orthopedic Car Seat)YPurchaseZ2047E0700NUU4((Orthopedic Car Seat)YPurchaseZ2047E0950EPU9((Tray for Stander-Prone)NPurchaseZ2003E0950NUU9((Tray for Stander-Prone)NPurchaseZ2003E0950EPUA((Tray for Stander-Supine)NPurchaseZ2004E0950NUUA((Tray for Stander-Supine)NPurchaseZ2004E1031EPU6((Mobile Floor Sitter Med/Lg.)NPurchaseZ2021**E1031EPU7((14 T&S High Back w/Support Activity Chair)YPurchaseZ2045**E1031EPU8((16 T&S High Back w/Support Activity Chair)YPurchaseZ2046**E1399EPU1((Tumble Form Feeder Seat - Sm.)NPurchaseZ2017**E1399EPU2((Tumble Form Feeder Seat - Med.)NPurchaseZ2018**E1399NUU2((Tumble Form Feeder Seat - Med.)NPurchaseZ2018**E1399EPU3((Tumble Form Feeder Seat - Lg.)NPurchaseZ2019**E8002EPU3((Adult Gait Trainer)Y(PurchaseZ2093E8002NUU3((Adult Gait Trainer)Y(PurchaseZ2093K0045EPU1((Foot Sandals for Standers)NPurchaseZ2005K0045NUU1((Foot Sandals for Standers)NPurchaseZ2005K0071EPU1((Caster Base for Up Rite Stander - Sm.)NPurchaseZ2009K0071NUU1((Caster Base for Up Rite Stander - Sm.)NPurchaseZ2009K0071EPU2((Caster Base for Up Rite Stander - Med.)NPurchaseZ2010K0071NUU2((Caster Base for Up Rite Stander - Med.)NPurchaseZ2010K0071EPU3((Caster Base for Up Rite Stander - Lg.)NPurchaseZ2011K0071NUU3((Caster Base for Up Rite Stander - Lg.)NPurchaseZ2011 242.193 Speech Generating Device for Beneficiaries of All Ages1-1-21The speech generating device must be billed using the procedure code assigned to each component. The specific components will be reimbursed, as needed, for the procedure codes listed below and will count toward the lifetime limit of $7,500 per beneficiary. Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU. Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a Y in the column; if not, an N is shown. NOTE: Attach a manufacturers invoice to the claim and indicate the item or parts billed on the invoice. A description and the amount billed for each item must be attached to the claim. If more than one item is billed under a procedure code, the description and billed amount of each item must be listed separately under each procedure code and attached to the claim. The total billed for each procedure code should be reflected in field 24F. ( Prior authorization is not required when other insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount. (() This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description. Speech Generating Device, All Ages (Section 242.193)National Procedure CodeM1M2PADescriptionPayment MethodE2500NU EPY(((Light Technology Communication Aids - communication aids that do not have the memory component to store the information. They are often used in conjunction with higher tech devices as part of a multi-modal communication system.) Speech-generating device, digitized speech, using pre-recorded messages less than or equal to 8 minutes recording timePurchaseE2502NU EPY(((Simple Voice Output Device - simple devices with limited storage capacity and voice output only.) Speech-generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20 minutes recording timePurchaseE2504NU EPY(((Simple Voice Output Device - simple devices with limited storage capacity and voice output only) Speech-generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording timePurchaseE2506NU EPY(((Simple Voice Output Device - simple devices with limited storage capacity and voice output only) Speech-generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time.PurchaseE2508NU EPY(((More Advanced Voice Output Communication Aids - offer more storage capacity and often have other output methods in addition to voice output; e.g., LED display) Speech-generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the devicePurchaseE2510NU EPY(((Higher Technology Voice Output Communication Aids - offer greater memory capabilities, various types of output, computer interface options, etc.) Speech-generating device synthesized speech, permitting multiple methods of message formulation and multiple methods of device accessPurchaseE2510NU EPY(((State-of-the-Art Voice Output Communication Aids - represents state-of-the-art communication aid technology. Have extensive memory capabilities, various output methods, computer interface options; offer a variety of input methods in a single device and advanced functions such as auditory scanning, icon and word prediction, etc.) Speech-generating device synthesized speech, permitting multiple methods of message formulation and multiple methods of device accessPurchaseE2511NU EPY(((Software - often recommended for speech generating device. Software may change as the child matures.) Speech-generating software program, for personal computer or personal digital assistantPurchaseE2512NU EPYAccessory for speech generating device, mounting systemManually PricedE2599NU EPY(((Switches - used with training aids and speech generating devices as a means of access) Accessory for speech generating device, not otherwise classifiedManually PricedV5336NU EPRP RPY((Speech Generating Device Repair - parts only) Repair/modification of speech generating system or device (excludes adaptive hearing aid)Manually PricedV5336NU EPY((Speech Generating Device Repair - labor only) Repair/modification of speech generating system or device (excludes adaptive hearing aid)Manually PricedNote: When repair charges for both parts and labor of the SGD is provided and/or billed on the same date of service, only one detail (parts only or labor only) of procedure code V5336 may be billed per beneficiary per date of service. Information must be specified on the paper claim to clarify the charges billed by the provider. Parts and labor charges must be itemized by narrative and documentation. A. The charge for parts must be clearly documented. A manufacturers invoice for the parts must be attached. B. The labor charge and the time represented by the labor charge must be clearly documented. 242.194 Replacement, Growth and Modification of Specialized Wheelchairs and Wheelchair Seating Systems 9-1-18Arkansas Medicaid will cover replacement equipment as needed due to growth, normal wear and tear, theft, irreparable damage or loss not covered by insurance. The following requirements must be met: A. Detailed documentation from the beneficiarys PCP or ordering physician /APRN describing the significant changes in the beneficiarys condition that require growth/modification or replacement must be submitted. B. The request must be submitted on form DMS-679 (Prescription & Prior Authorization Request for Medical Equipment). HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679.doc"View or print form DMS-679 and instructions for completion. C. An Evaluation for Wheelchair and Wheelchair Seating form (DMS-0843) must be submitted. The evaluation must be signed and dated by the beneficiarys PCP/APRN or ordering physician. The signature must be an original signature. A stamped signature will not be accepted by Arkansas Medicaid. An electronic signature will be accepted. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-0843.doc"View or print form DMS-0843. D. A manufacturers suggested retail price list and a manufacturers quote must be submitted. A quote created by the DME provider will not be accepted. E. Requests for replacement where malicious damage, neglect or misuse of the equipment may have occurred may be investigated by Arkansas Medicaid. Requests may be denied if such circumstances are confirmed. F. If a wheelchair is stolen or damaged by vehicle, fire or in the home, the beneficiary must provide the following with the request: 1. A police or fire report. 2. Copy of the homeowners or auto insurance coverage. 3. Detailed documentation of events leading to the loss and damage. If Arkansas Medicaid denies a repair or replacement in a case of malicious damage or misuse, payment of repairs is the responsibility of the beneficiary or caregiver. 242.195 Repairs of Specialized Wheelchairs and Wheelchair Systems5-1-17A. Arkansas Medicaid will cover repairs for wheelchairs and wheelchair seating. B. Repair services must receive prior authorization from AFMC. C. Detailed documentation from the technician that supports the equipment or services being requested must be submitted. Documentation must include the following: 1. Date and place of purchase of the current chair. 2. Brand and model name of the base. 3. Brand and model name of parts and accessories needed for repairs. D. Correct procedure codes per the current Medicaid policy must be used. E. Requests for repairs must be submitted on form DMS-679 (Prescription & Prior Authorization Request for Medical Equipment) and must be signed and dated by the beneficiarys PCP or ordering physician. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/DMS-679.doc"View or print form DMS-679 and instructions for completion. F. Repairs for previously authorized wheelchairs that the beneficiary has outgrown will not be covered if a new chair has been authorized. G. In the event a request is submitted for repairs for a wheelchair authorized by another state agency, documentation or a delivery ticket showing that the wheelchair was authorized by another state agency must be submitted with the request. H. Arkansas Medicaid will not cover repairs/damage due to the following: 1. Neglect. 2. Misuse. 3. Abuse. 4. Improper installation or repair by the DME provider. 5. Use of parts or changes by the DME provider or the beneficiary not authorized by Arkansas Medicaid. I. When a request is submitted for a new wheelchair with a statement that the previous wheelchair cannot be repaired, documentation from the manufacturer of the previous chair stating the reason why the previous wheelchair cannot be repaired must be included. J. If the previous wheelchair cannot be repaired, several color photographs taken at different angles must be included with the new request. Miscellaneous A wheelchair can be ordered only by a physician. A physicians evaluation is valid for a period of six (6) months. After six (6) months, the beneficiary must be re-evaluated by the physician to determine medical necessity for continued need because conditions and measurements do change. A DME request is considered to be outdated by Medicaid when it is first presented to Medicaid more than ninety (90) days from the date it was written, signed and dated by the physician. 242.200 National Place of Service and Modifier Codes7-1-07Electronic and paper claims require the same national place of service (POS) code. Place of ServicePOS CodesInpatient Hospital21Outpatient Hospital22Doctors Office11Patients Home12Day Care Facility52Night Care Facility52Nursing Facility32Skilled Nursing Facility31Ambulance41Other Locations99Independent Laboratory81Ambulatory Surgical Center24Residential Treatment Center56Specialized Treatment Facility56Comprehensive Outpatient Rehabilitative Facility62Independent Kidney Disease Treatment Center65Inpatient Psychiatric Facility51ModifiersEP-Service provided as part of EPSDT ProgramKH-Durable Medical Equipment (DME) item, initial claim, first month's rentalNU-New EquipmentRR-Durable Medical Equipment (DME) Rental U1-Medicaid Level of Care 1 (defined by state)U2-Medicaid level of Care 2 (defined by state)U3-Medicaid level of care 3 (defined by state)U4-Medicaid level of care 4 (defined by state)U5-Medicaid level of care 5 (defined by state)UE-Used durable medical equipment (DME)52-Reduced Services 242.300 Billing Instructions - Paper Only11-1-17Bill Medicaid for professional services with form CMS-1500. The numbered items in the following instructions correspond to the numbered fields on the claim form. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/SampleCMS-1500.pdf"View a sample form CMS-1500. Carefully follow these instructions to help the Arkansas Medicaid fiscal agent efficiently process claims. Accuracy, completeness, and clarity are essential. Claims cannot be processed if necessary information is omitted. Forward completed claim forms to the Claims Department. HYPERLINK "https://humanservices.arkansas.gov/wp-content/uploads/Claims.doc"View or print the Claims Department contact information. NOTE: A provider delivering services without verifying beneficiary eligibility for each date of service does so at the risk of not being reimbursed for the services. 242.310 Completion of CMS-1500 Claim Form9-1-18 Field Name and NumberInstructions for Completion1. (type of coverage)Not required.1a. INSUREDS I.D. NUMBER (For Program in Item 1)Beneficiarys or participants 10-digit Medicaid or ARKids First-A or ARKids First-B identification number.2. PATIENTS NAME (Last Name, First Name, Middle Initial)Beneficiarys or participants last name and first name.3. PATIENTS BIRTH DATE Beneficiarys or participants date of birth as given on the individuals Medicaid or ARKids First-A or ARKids First-B identification card. Format: MM/DD/YY. SEXCheck M for male or F for female.4. INSUREDS NAME (Last Name, First Name, Middle Initial)Required if insurance affects this claim. Insureds last name, first name, and middle initial.5. PATIENTS ADDRESS (No. Street)Optional. Beneficiarys or participants complete mailing address (street address or post office box). CITYName of the city in which the beneficiary or participant resides. STATETwo-letter postal code for the state in which the beneficiary or participant resides. ZIP CODEFive-digit zip code; nine digits for post office box. TELEPHONE (Include Area Code)The beneficiarys or participants telephone number or the number of a reliable message/contact/ emergency telephone.6. PATIENT RELATIONSHIP TO INSUREDIf insurance affects this claim, check the box indicating the patients relationship to the insured.7. INSUREDS ADDRESS (No., Street)Required if insureds address is different from the patients address. CITY STATE ZIP CODE TELEPHONE (Include Area Code)8. RESERVEDReserved for NUCC use.9. OTHER INSUREDS NAME (Last name, First Name, Middle Initial)If patient has other insurance coverage as indicated in Field 11d, the other insureds last name, first name, and middle initial.a. OTHER INSUREDS POLICY OR GROUP NUMBERPolicy and/or group number of the insured individual.b. RESERVEDReserved for NUCC use.SEXNot required.c. RESERVEDReserved for NUCC use.d. INSURANCE PLAN NAME OR PROGRAM NAMEName of the insurance company.10. IS PATIENTS CONDITION RELATED TO:a. EMPLOYMENT? (Current or Previous)Check YES or NO.b. AUTO ACCIDENT? Required when an auto accident is related to the services. Check YES or NO. PLACE (State)If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place.c. OTHER ACCIDENT?Required when an accident other than automobile is related to the services. Check YES or NO.d. CLAIM CODESThe Claim Codes identify additional information about the beneficiarys condition or the claim. When applicable, use the Claim code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition codes, enter the condition codes in this field. The subset of approved Condition Codes is found at  HYPERLINK "http://www.nucc.org" www.nucc.org under Code Sets.11. INSUREDS POLICY GROUP OR FECA NUMBERNot required when Medicaid is the only payer.a. INSUREDS DATE OF BIRTHNot required. SEXNot required.b. OTHER CLAIM ID NUMBERNot required.c. INSURANCE PLAN NAME OR PROGRAM NAMENot required.d. IS THERE ANOTHER HEALTH BENEFIT PLAN?When private or other insurance may or will cover any of the services, check YES and complete items 9, 9a and 9d. Only one box can be marked.12. PATIENTS OR AUTHORIZED PERSONS SIGNATUREEnter Signature on File, SOF or legal signature.13. INSUREDS OR AUTHORIZED PERSONS SIGNATURE Enter Signature on File, SOF or legal signature.14. DATE OF CURRENT: ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP)Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident. Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current Symptoms or Illness; 484 Last Menstrual Period.15. OTHER DATEEnter another date related to the beneficiarys condition or treatment. Enter the qualifier between the left-hand set of vertical, dotted lines. The Other Date identifies additional date information about the beneficiarys condition or treatment. Use qualifiers: 454 Initial Treatment 304 Latest Visit or Consultation 453 Acute Manifestation of a Chronic Condition 439 Accident 455 Last X-Ray 471 Prescription 090 Report Start (Assumed Care Date) 091 Report End (Relinquished Care Date) 444 First Visit or Consultation16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION Not required.17. NAME OF REFERRING PROVIDER OR OTHER SOURCEPrimary Care Physician (PCP)/Advanced Practice Registered Nurse (APRN) referral is not required for prosthetics. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title.17a. (blank)Not required. 17b. NPIEnter NPI of the referring physician.18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICESWhen the serving/billing providers services charged on this claim are related to a beneficiarys or participants inpatient hospitalization, enter the individuals admission and discharge dates. Format: MM/DD/YY.19. ADDITIONAL CLAIM INFORMATIONIdentifies additional information about the beneficiarys condition or the claim. Enter the appropriate qualifiers describing the identifier. See  HYPERLINK "http://www.nucc.org" www.nucc.org for qualifiers.20. OUTSIDE LAB?Not required. $ CHARGESNot required.21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURYEnter the applicable ICD indicator to identify which version of ICD codes is being reported. Use 9 for ICD-9-CM. Use 0 for ICD-10-CM. Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field. Diagnosis code for the primary medical condition for which services are being billed. Use the appropriate International Classification of Diseases (ICD). List no more than 12 diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line. Use the highest level of specificity.22. RESUBMISSION CODE Reserved for future use. ORIGINAL REF. NO.Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy.23. PRIOR AUTHORIZATION NUMBERThe prior authorization or benefit extension control number if applicable.24A. DATE(S) OF SERVICEThe from and to dates of service for each billed service. Format: MM/DD/YY. 1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month. 2. Providers may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of the service on each day of the date sequence.B. PLACE OF SERVICETwo-digit national standard place of service code. See Section 242.200 for codes.C. EMG Enter Y for Yes or leave blank if No. EMG identifies if the service was an emergency.D. PROCEDURES, SERVICES, OR SUPPLIES CPT/HCPCSEnter the correct CPT or HCPCS procedure code from Sections 242.100 through 242.195. MODIFIERModifier(s) if applicable.E. DIAGNOSIS POINTEREnter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow. The reference letter(s) should be A-L or multiple letters as applicable. The Diagnosis Pointer is the line letter from Item Number 21 that relates to the reason the service(s) was performed.F. $ CHARGESThe full charge for the service(s) totaled in the detail. This charge must be the usual charge to any client, patient, or other beneficiary of the providers services.G. DAYS OR UNITSThe units (in whole numbers) of service(s) provided during the period indicated in Field 24A of the detail. H. EPSDT/Family PlanEnter E if the services resulted from a Child Health Services (EPSDT) screening/referral.I. ID QUALNot required.J. RENDERING PROVIDER ID #Enter the 9-digit Arkansas Medicaid provider ID number of the individual who furnished the services billed for in the detail or NPIEnter NPI of the individual who furnished the services billed for in the detail.25. FEDERAL TAX I.D. NUMBERNot required. This information is carried in the providers Medicaid file. If it changes, please contact Provider Enrollment.26. PATIENTS ACCOUNT N O.Optional entry that may be used for accounting purposes; use up to 16 numeric or alphabetic characters. This number appears on the Remittance Advice as MRN.27. ACCEPT ASSIGNMENT?Not required. Assignment is automatically accepted by the provider when billing Medicaid.28. TOTAL CHARGETotal of Column 24Fthe sum all charges on the claim.29. AMOUNT PAIDEnter the total of payments previously received on this claim. Do not include amounts previously paid by Medicaid. *Do not include in this total the automatically deducted Medicaid or ARKids First-B co-payments.30. RESERVEDReserved for NUCC use.31. SIGNATURE OF PHYSICIAN/ADVANCED PRACTICE REGISTERED NURSE OR SUPPLIER INCLUDING DEGREES OR CREDENTIALSThe provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the providers direction. Providers signature is defined as the providers actual signature, a rubber stamp of the providers signature, an automated signature, a typewritten signature, or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. 32. SERVICE FACILITY LOCATION INFORMATIONIf other than home or office, enter the name and street, city, state, and zip code of the facility where services were performed. a. (blank)Not required. b. (blank)Not required.33. BILLING PROVIDER INFO & PH #Billing providers name and complete address. Telephone number is requested but not required.a. (blank)Enter NPI of the billing provider orb. (blank)Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider. 242.400 Special Billing Procedures242.401 National Drug Codes (NDCs)7-1-20Effective for claims with dates of service on or after January 1, 2008, Arkansas Medicaid implemented billing protocol per the Federal Deficit Reduction Act of 2005. This explains policy and billing protocol for providers that submit claims for drug HCPCS/CPT codes with dates of service on and after January 1, 2008. The Federal Deficit Reduction Act of 2005 mandates that Arkansas Medicaid require the submission of National Drug Codes (NDCs) on claims submitted with Health Care Common Procedure Coding System, Level II/Current Procedural Terminology, 4th edition (HCPCS/CPT) codes for drugs administered. The purpose of this requirement is to assure that the State Medicaid Agencies obtain a rebate from those manufacturers who have signed a rebate agreement with the Centers for Medicare and Medicaid Services (CMS). A. Covered Labelers Arkansas Medicaid, by statute, will only pay for a drug procedure billed with an NDC when the pharmaceutical labeler of that drug is a covered labeler with Centers for Medicare and Medicaid Services (CMS). A covered labeler is a pharmaceutical manufacturer that has entered into a federal rebate agreement with CMS to provide each state a rebate for products reimbursed by Medicaid Programs. A covered labeler is identified by the first five (5) digits of the NDC. To assure a product is payable for administration to a Medicaid beneficiary, compare the labeler code (the first five (5) digits of the NDC) to the list of covered labelers which is maintained on the  HYPERLINK "https://arkansas.magellanrx.com/provider/documents/" DHS contracted Pharmacy vendor website . A complete listing of Covered Labelers is located on the website. See Diagram 1 for an example of this screen. The effective date is when a manufacturer entered into a rebate agreement with CMS. The Labeler termination date indicates that the manufacturer no longer participates in the federal rebate program and therefore the products cannot be reimbursed by Arkansas Medicaid on or after the termination date. Diagram 1  For a claim with drug HCPCS/CPT codes to be eligible for payment, the detail date of service must be prior to the NDC termination date. The NDC termination date represents the shelf-life expiration date of the last batch produced, as supplied on the Centers for Medicare and Medicaid Services (CMS) quarterly update. The date is supplied to CMS by the drug manufacturer/distributor. Arkansas Medicaid will deny claim details with drug HCPCS/CPT codes with a detail date of service equal to or greater than the NDC termination date. When completing a Medicaid claim for administering a drug, indicate the HIPAA standard 11-digit NDC with no dashes or spaces. The 11-digit NDC is comprised of three (3) segments or codes: a 5-digit labeler code, a 4-digit product code, and a 2-digit package code. The 10-digit NDC assigned by the FDA printed on the drug package must be changed to the 11-digit format by inserting a leading zero (0) in one (1) of the three (3) segments. Below are examples of the FDA assigned NDC on a package changed to the appropriate 11-digit HIPAA standard format. Diagram 2 displays the labeler code as five (5) digits with leading zeros; the product code as four (4) digits with leading zeros; the package code as two (2) digits without leading zeros, using the 5-4-2 format. Diagram 2 00123045678LABELER CODE (5 digits)PRODUCT CODE (4 digits)PACKAGE CODE (2 digits) NDCs submitted in any configuration other than the 11-digit format will be rejected/denied. NDCs billed to Medicaid for payment must use the 11-digit format without dashes or spaces between the numbers. See Diagram 3 for sample NDCs as they might appear on drug packaging and the corresponding format which should be used for billing Arkansas Medicaid: Diagram 3 10-digit FDA NDC on PACKAGERequired 11-digit NDC (5-4-2) Billing Format12345 6789 1123456789011111-2222-330111122223301111 456 7101111045671 B. Drug Procedure Code (HCPCS/CPT) to NDC Relationship and Billing Principles HCPCS/CPT codes and any modifiers will continue to be billed per the policy for each procedure code. However, the NDC and NDC quantity of the administered drug is now also required for correct billing of drug HCPCS/CPT codes. To maintain the integrity of the drug rebate program, it is important that the specific NDC from the package used at the time of the procedure be recorded for billing. HCPCS/CPT codes submitted using invalid NDCs or NDCs that were unavailable on the date of service will be rejected/denied. We encourage you to enlist the cooperation of all staff members involved in drug administration to assure collection or notation of the NDC from the actual package used. It is not recommended that billing of NDCs be based on a reference list, as NDCs vary from one (1) labeler to another, from one (1) package size to another, and from one (1) time period to another. Exception: There is no requirement for an NDC when billing for vaccines, radiopharmaceuticals, and allergen immunotherapy. II. Claims Filing The HCPCS/CPT codes billing units and the NDC quantity do not always have a one-to-one relationship. Example 1: The HCPCS/CPT code may specify up to 75 mg of the drug whereas the NDC quantity is typically billed in units, milliliters or grams. If the patient is provided 2 oral tablets, one at 25 mg and one at 50 mg, the HCPCS/CPT code unit would be 1 (1 total of 75 mg) in the example whereas the NDC quantity would be 1 each (1 unit of the 25 mg tablet and 1 unit of the 50 mg tablet). See Diagram 4. Diagram 4  Example 2: If the drug in the example is an injection of 5 ml (or cc) of a product that was 50 mg per 10 ml of a 10 ml single-use vial, the HCPCS/CPT code unit would be 1 (1 unit of 25 mg) whereas the NDC quantity would be 5 (5 ml). In this example, 5 ml or 25 mg would be documented as wasted. See Diagram 5. Diagram 5  A. Electronic Claims Filing 837P (Professional) and 837I (Outpatient) Procedure codes that do not require paper billing may be billed electronically. Any procedure codes that have required modifiers in the past will continue to require modifiers. Arkansas Medicaid requires providers using electronic filing through the Provider Portal to use the required NDC format when billing HCPCS/CPT codes for administered drugs. B. Paper Claims Filing CMS-1500 Arkansas Medicaid will require providers billing drug HCPCS/CPT codes including covered unlisted drug procedure codes to use the required NDC format. See Diagram 6 for CMS-1500. For professional claims, CMS-1500, list the qualifier of N4, the 11-digit NDC, the unit of measure qualifier (F2 International Unit; GR Gram; ML - Milliliter; UN Unit), and the number of units of the actual NDC administered in the shaded area above detail field 24A, spaced and arranged exactly as in Diagram 6. Each NDC when billed under the same procedure code on the same date of service is defined as a sequence. When billing a single HCPCS/CPT code with multiple NDCs as detail sequences, the first sequence should reflect the total charges in detail field 24F and total HCPCS/CPT code units in detail field 24G. Each subsequent sequence number should show zeros in detail fields 24F and 24G. See Detail 1, sequence 2 in Diagram 6. The quantity of the NDC will be the total number of units billed for each specific NDC. See Diagram 6, first detail, sequences 1 and 2. Detail 2 is a Procedure Code that does not require an NDC. Detail 3, sequence 1 gives an example where only one (1) NDC is associated with the HCPCS/CPT code. Diagram 6  Procedure Code/NDC Detail Attachment FormDMS-664 For drug HCPCS/CPT codes requiring paper billing (i.e., for manual review), complete every field of the DMS-664 Procedure Code/NDC Detail Attachment Form. Attach this form and any other required documents to your claim when submitting it for processing. See Diagram 7 for an example of the completed form. Section V of the provider manual includes this form. Diagram 7  III. Adjustments Paper adjustments for paid claims filed with NDC numbers will not be accepted. Any original claim will have to be voided and a replacement claim will need to be filed. Providers have the option of adjusting a paper or electronic claim electronically. IV. Remittance Advices Only the first sequence in a detail will be displayed on the remittance advice reflecting either the total amount paid or the denial EOB(s) for the detail. V. Record Retention Each provider must retain all records for five (5) years from the date of service or until all audit questions, dispute or review issues, appeal hearings, investigations or administrative/judicial litigation to which the records may relate are concluded, whichever period is longer. At times, a manufacturer may question the invoiced amount, which results in a drug rebate dispute. If this occurs, you may be contacted requesting a copy of your office records to include documentation pertaining to the billed HCPCS/CPT code. Requested records may include NDC invoices showing purchase of drugs and documentation showing what drug (name, strength and amount) was administered and on what date, to the beneficiary in question. 242.402 Billing of Multi-Use and Single-Use Vials11-1-15Arkansas Medicaid follows the billing protocol per the Federal Deficit Reduction Act of 2005 for drugs. A. Multiple units may be billed when applicable. Take-home drugs are not covered. Drugs loaded into an infusion pump are not classified as take-home drugs. Refer to payable CPT code ranges 96365 through 96379. B. When submitting Arkansas Medicaid drug claims, drug units should be reported in multiples of the dosage included in the HCPCS procedure code description. 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0$IfgdJ666677777$7@7F7G7H7c77777778888c8888888899c999999::&:':?:B:E:Q:_:b:c:q:r:x:{:|::::::::::::;;;';);:;;;A;D;hzhJ5B*\phhzhJ5hzhJCJ jhzhJhzhJ5B*CJ\ph hzhJL66677$7=4444 ,$IfgdJkdX$$Ifl4ֈh $ 0(#4 layt5=$7@7F7G7H7501gd5=kd$$Iflֈh $ 0(#4 layt5= ,$IfgdJH7777889&:':?:B:tooojeZZ 0$$IfgdJ1gd5=3gd5=gd5=ykd$$Ifl40N$$0$64 laf4yt5= ($IfgdJ $IfgdJ B:E:Q:_:b:q: 0$$IfgdJq:r:x:{:' ,$IfgdJkd$$Ifl44֞o 7 Is2$:: v0"4 laf4yt5={:|::::: ,$IfgdJ::::( ,$IfgdJkdf$$Ifl4֞o 7 Is2$:: v0"4 laf4yt5=::;';);:; ,$IfgdJ:;;;A;D;( ,$IfgdJkd1$$Ifl4֞o 7 Is2$:: v0"4 laf4yt5=D;E;c;;;;;;;;;;;;;<<(<)<+<,<-<.<N<c<<<<===c==========>> >>]>c>>>>??-?W?\?`?c?f?????@@Y@a@c@l@@@@@@@@@@@@@@@@@A hzhhzhJ5hzhJ5>* jhzhJ hzhJTD;E;;;;; ,$IfgdJ;;;;( ,$IfgdJkd$$Ifl4֞o 7 Is2$:: v0"4 laf4yt5=;;(<)<+<,< ,$IfgdJ,<-<.<N<(#gd5=1gd5=kd$$Ifl4֞o 7 Is2$:: v0"4 laf4yt5=N<==]>-??Y@@@@Aoa V ^gdykd$$Ifl40N$$0$64 laf4yt5= ($Ifgd $Ifgdgd5= AAA%ABAcAAAAAAAAAAAABBBBB"B%B(B4BCBDBIBJBKBLBNBVBYB^BcBgBhBmBnBqBtBvBzB~BBBBBBBBBBBBCCCCCCCC C Q 2$)0"4 layt5=NB^BgBhBnBqB2kd$$Ifl4ֈo+ > Q 2$)0"4 laf4yt5= ,$Ifgd Q 2$)0"4 laf4yt5= ,$Ifgd Q 2$)0"4 laf4yt5= CVC_C`CfCiC2kd$$Ifl4ֈo+ > Q 2$)0"4 laf4yt5= ,$Ifgd Q 2$)0"4 laf4yt5= ,$Ifgd*hzhJ5 hzhJhzh Q 2$)0"4 laf4yt5=DNDWDXD^DaD2kd+$$Ifl4ֈo+ > Q 2$)0"4 laf4yt5= ,$Ifgd Q 2$)0"4 laf4yt5= ,$Ifgd90' ($IfgdJ $IfgdJ1gd5=kd$$Iflֈo+ > Q 2$)0"4 layt5=DDEEEEEEEE|ssssss 0$IfgdJ1gd5=gd5=ykd2$$Ifl40N$$0$64 laf4yt5= EEEEEE;2222 ,$IfgdJkd$$Ifl4ֈo+ > Q 2$:T0"4 layt5=EEEEEFFFF FcFFFFFFFFFFFGcGGGGGGGGGGGGGGGGGGGHHH HHHMH\HaHcHHHHHHHIcIhIIIIIIIIIIII÷÷÷÷÷÷÷÷÷hzhJ5mH sH hzhJmH sH hzhJ5\mH sH hzhJ5\ hzhJhzhJCJ\hzhJ\FEFFF F2-1gd5=kd$$Ifl4ֈo+ > Q 2$:T0"4 laf4yt5= ,$IfgdJ FFFFIIIIIIrmh]]]] 0$$IfgdJ1gd5=gd5=ykd`$$Ifl40N$$0$64 laf4yt5= ($IfgdJ $$IfgdJ IIII!kd)$$Ifl44ֈo !V **0m 4 laf4yt5= 0$$IfgdJ 0$$$Ifa$gdJIIIIIJ]?]E]N]O]P]R]c]]]]]]]]]]]]]]]]]]]]^;^D^E^K^T^U^V^X^hzhJCJhzhJCJH*hzhJ5\ hzhJWc[d[e[g[[[ ,$IfgdJ[[[[( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=[[[[;\D\ ,$IfgdJD\E\K\T\( ,$IfgdJkdS $$Ifl4֞h* N jX2$]0"4 laf4yt5=T\U\V\X\\\ ,$IfgdJ\\\\( ,$IfgdJkd $$Ifl4֞h* N jX2$]0"4 laf4yt5=\\\\\\ ,$IfgdJ\\\\( ,$IfgdJkd $$Ifl4֞h* N jX2$]0"4 laf4yt5=\\\\5]>] ,$IfgdJ>]?]E]N]( ,$IfgdJkd $$Ifl4֞h* N jX2$]0"4 laf4yt5=N]O]P]R]]] ,$IfgdJ]]]]( ,$IfgdJkd $$Ifl4֞h* N jX2$]0"4 laf4yt5=]]]]]] ,$IfgdJ]]]]( ,$IfgdJkdJ $$Ifl4֞h* N jX2$]0"4 laf4yt5=]]]];^D^ ,$IfgdJD^E^K^T^( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=T^U^V^X^^^ ,$IfgdJX^c^^^^^^^^^^^^^^^^^^^^_'_0_1_6_7_=_>_?_A_Y_b_c_i_r_s_t_v______________________`3`<`=`C`L`M`N`P`c````````````aaaa a)a*a+a-aXahzhJCJH*hzhJ5\ hzhJZ^^^^( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=^^^^^^ ,$IfgdJ^^^^( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=^^^^'_0_ ,$IfgdJ0_1_7_=_( ,$IfgdJkdv$$Ifl4֞h* N jX2$]0"4 laf4yt5==_>_?_A_Y_b_ ,$IfgdJb_c_i_r_( ,$IfgdJkdA$$Ifl4֞h* N jX2$]0"4 laf4yt5=r_s_t_v___ ,$IfgdJ____( ,$IfgdJkd $$Ifl4֞h* N jX2$]0"4 laf4yt5=______ ,$IfgdJ____( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=____3`<` ,$IfgdJ<`=`C`L`( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=L`M`N`P``` ,$IfgdJ````( ,$IfgdJkdm$$Ifl4֞h* N jX2$]0"4 laf4yt5=````aa ,$IfgdJaa a)a( ,$IfgdJkd8$$Ifl4֞h* N jX2$]0"4 laf4yt5=)a*a+a-aXaaa ,$IfgdJXaaabacahaqarasauaaaaaaaaaaaaaaaaabb2b@bAbGbPbQbRbTbcbvbbbbbbbbbbbbbbbbbbbbcccc$c*c+c,c.cDcMcNcTcZc[c\c^cccvccccccccccccccccchzhJCJH*hzhJ5\ hzhJZaabahaqa( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=qarasauaaa ,$IfgdJaaaa( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=aaaaaa ,$IfgdJaaaa( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=aabb2b@b ,$IfgdJ@bAbGbPb( ,$IfgdJkdd$$Ifl4֞h* N jX2$]0"4 laf4yt5=PbQbRbTbvbb ,$IfgdJbbbb( ,$IfgdJkd/$$Ifl4֞h* N jX2$]0"4 laf4yt5=bbbbbb ,$IfgdJbbbb( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=bbbbcc ,$IfgdJcc$c*c( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=*c+c,c.cDcMc ,$IfgdJMcNcTcZc( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=Zc[c\c^cvcc ,$IfgdJcccc( ,$IfgdJkd[$$Ifl4֞h* N jX2$]0"4 laf4yt5=cccccc ,$IfgdJcccc( ,$IfgdJkd&$$Ifl4֞h* N jX2$]0"4 laf4yt5=cccccddddddddddcdrd{d|dddddddddddddddddddeQeZe[eaecedegehejekeeeeeeeeeeeeeef0f9f:f@fCfFfGfIfJfcffffffffffffffgggggg jhzhJhzhJ5\ hzhJZccccdd ,$IfgdJdddd( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=ddddrd{d ,$IfgdJ{d|ddd( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=dddddd ,$IfgdJdddd( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=ddddQeZe ,$IfgdJZe[eaede( ,$IfgdJkdR $$Ifl4֞h* N jX2$]0"4 laf4yt5=degehejeee ,$IfgdJeeee( ,$IfgdJkd!$$Ifl4֞h* N jX2$]0"4 laf4yt5=eeee0f9f ,$IfgdJ9f:f@fCf( ,$IfgdJkd!$$Ifl4֞h* N jX2$]0"4 laf4yt5=CfFfGfIfff ,$IfgdJffff( ,$IfgdJkd"$$Ifl4֞h* N jX2$]0"4 laf4yt5=ffffgg ,$IfgdJgggg( ,$IfgdJkd~#$$Ifl4֞h* N jX2$]0"4 laf4yt5=ggg g!gcgtg}g~gggggggggggggggggggghQhZh[hahchdhghjhlhmhhhhhhhhhhhhhhhi1i2i4i=i>iDiGiIiJiKiNiPiQiciiiiiiiiiiiiiiiiihzhJH*hzhJhhzhJ5\ jhzhJ hzhJSggg gtg}g ,$IfgdJ}g~ggg( ,$IfgdJkdI$$$Ifl4֞h* N jX2$]0"4 laf4yt5=gggggg ,$IfgdJgggg( ,$IfgdJkd%$$Ifl4֞h* N jX2$]0"4 laf4yt5=ggggQhZh ,$IfgdJZh[hahdh( ,$IfgdJkd%$$Ifl4֞h* N jX2$]0"4 laf4yt5=dhghjhlhhh ,$IfgdJhhhh( ,$IfgdJkd&$$Ifl4֞h* N jX2$]0"4 laf4yt5=hhhh4i=i ,$IfgdJ=i>iDiGi( ,$IfgdJkdu'$$Ifl4֞h* N jX2$]0"4 laf4yt5=GiKiNiPiii ,$IfgdJiiii( ,$IfgdJkd@($$Ifl4֞h* N jX2$]0"4 laf4yt5=iiiiii ,$IfgdJiiii( ,$IfgdJkd )$$Ifl4֞h* N jX2$]0"4 laf4yt5=iiiiiiijj-j.j3j4j:j;jjTj]j^jcjdjmjnjojqjjjjjjjjjjjjjkkkk!k*k+k,k.kckykkkkkkkkkkkkkkkkkkkklll#l$l*l3l4l5l7lclpl~lllllllhzhJCJH*hzhJ5\ jhzhJ hzhJViiiij-j ,$IfgdJ-j.j4j:j( ,$IfgdJkd)$$Ifl4֞h* N jX2$]0"4 laf4yt5=:j;jjTj]j ,$IfgdJ]j^jdjmj( ,$IfgdJkd*$$Ifl4֞h* N jX2$]0"4 laf4yt5=mjnjojqjjj ,$IfgdJjjjj( ,$IfgdJkdl+$$Ifl4֞h* N jX2$]0"4 laf4yt5=jjjjkk ,$IfgdJkk!k*k( ,$IfgdJkd7,$$Ifl4֞h* N jX2$]0"4 laf4yt5=*k+k,k.kykk ,$IfgdJkkkk( ,$IfgdJkd-$$Ifl4֞h* N jX2$]0"4 laf4yt5=kkkkkk ,$IfgdJkkkk( ,$IfgdJkd-$$Ifl4֞h* N jX2$]0"4 laf4yt5=kkkkll#l ,$IfgdJ#l$l*l3l( ,$IfgdJkd.$$Ifl4֞h* N jX2$]0"4 laf4yt5=3l4l5l7lpl~l ,$IfgdJ~llll( ,$IfgdJkdc/$$Ifl4֞h* N jX2$]0"4 laf4yt5=llllll ,$IfgdJllllllllllllllmm mmmmmmcmfmompmvmmmmmmmmmmmmmmmmmmmmmmmmn(n1n2n7n8n>nDnEnGncnonxnyn~nnnnnnnnnnnnnnnnnnooo oohzhJmH sH hzhJCJH*hzhJ5\ hzhJVllll( ,$IfgdJkd.0$$Ifl4֞h* N jX2$]0"4 laf4yt5=lllllm ,$IfgdJm mmm( ,$IfgdJkd0$$Ifl4֞h* N jX2$]0"4 laf4yt5=mmmmfmom ,$IfgdJompmvmm( ,$IfgdJkd1$$Ifl4֞h* N jX2$]0"4 laf4yt5=mmmmmm ,$IfgdJmmmm( ,$IfgdJkd2$$Ifl4֞h* N jX2$]0"4 laf4yt5=mmmmmm ,$IfgdJmmmm( ,$IfgdJkdZ3$$Ifl4֞h* N jX2$]0"4 laf4yt5=mmmn(n1n ,$IfgdJ1n2n8n>n( ,$IfgdJkd%4$$Ifl4֞h* N jX2$]0"4 laf4yt5=>nDnEnGnonxn ,$IfgdJxnynnn( ,$IfgdJkd4$$Ifl4֞h* N jX2$]0"4 laf4yt5=nnnnnn ,$IfgdJnnnn( ,$IfgdJkd5$$Ifl4֞h* N jX2$]0"4 laf4yt5=nnnnno ,$IfgdJoo oo( ,$IfgdJkd6$$Ifl4֞h* N jX2$]0"4 laf4yt5=oooo*o3o4o=oCoIoJoLoMoco}ooooooooooooooooooooooppp!p"p'p(p.p/p0p2pcpmpnpwpxp}p~ppppppppppppppppppq qqqq q!q"qhzhJB*phhzhJCJhzhJCJH* jhzhJhzhJ5\ hzhJNoooo*o3o ,$IfgdJ3o4o=oCo( ,$IfgdJkdQ7$$Ifl4֞h* N jX2$]0"4 laf4yt5=CoIoJoLo}oo ,$IfgdJoooo( ,$IfgdJkd8$$Ifl4֞h* N jX2$]0"4 laf4yt5=oooooo ,$IfgdJoooo( ,$IfgdJkd8$$Ifl4֞h* N jX2$]0"4 laf4yt5=oooop!p ,$IfgdJ!p"p(p.p( ,$IfgdJkd9$$Ifl4֞h* N jX2$]0"4 laf4yt5=.p/p0p2pnpwp ,$IfgdJwpxp~pp( ,$IfgdJkd}:$$Ifl4֞h* N jX2$]0"4 laf4yt5=pppppp ,$IfgdJpppp( ,$IfgdJkdH;$$Ifl4֞h* N jX2$]0"4 laf4yt5=pppp qq ,$IfgdJqqq q( ,$IfgdJkd<$$Ifl4֞h* N jX2$]0"4 laf4yt5= q!q"qKqqq ,$IfgdJ"q#q$qFqGqHqIqJqKqLqcqqqqqqqqqqqqqqrrrrrrrbrcrprqrwr}r~rrrrrrrrrrrrrrrsss sssss8sj?hzhJUj0>hzhJUhzhJB*phhzhJ5\ jhzhJ jhzhJ5j<hzhJUjhzhJU hzhJ$$Ifl4֞h* N jX2$]0"4 laf4yt5=}r~rrrrs ,$IfgdJsss s( ,$IfgdJkd @$$Ifl4֞h* N jX2$]0"4 laf4yt5= sss=sss ,$IfgdJ8s9s:s;se$$Ifl4֞h* N jX2$]0"4 laf4yt5=|||||||||||}t}}Ffg ,$IfgdJ ||}}}}}}}c}t}}}}}}}}}}}}}}}}}}}}}}~~~~~~(~1~2~8~A~B~C~E~]~c~k~l~u~{~|~}~~~~~~~~~~~~~~~~~~~~~~~hzhJ5\ jhzhJ5jhzhJUjhhzhJU hzhJM}}}}( ,$IfgdJkdi$$Ifl4֞h* N jX2$]0"4 laf4yt5=}}}}}} ,$IfgdJ}}}}( ,$IfgdJkdPj$$Ifl4֞h* N jX2$]0"4 laf4yt5=}}}}}}~~~~~~(~1~2~8~A~B~C~E~]~k~l~u~{~|~}~FfrFfoFf%l ,$IfgdJ}~~~~~~~~~~~~Ffu ,$IfgdJ ~~~~( ,$IfgdJkdv$$Ifl4֞h* N jX2$]0"4 laf4yt5=~~~"N\ ,$IfgdJ !"N\]clmnop   UcdjpqrstԼԮԠj{hzhJUj^zhzhJUj yhzhJUhzhJ5\ hzhJ jhzhJ5jhzhJUjwhzhJU?\]c( ,$IfgdJkdAx$$Ifl4֞h* N jX2$]0"4 laf4yt5=clmn ,$IfgdJ , f$IfgdJ( ,$IfgdJkdy$$Ifl4֞h* N jX2$]0"4 laf4yt5= Uc ,$IfgdJ , $IfgdJcdjp( ,$IfgdJkdz$$Ifl4֞h* N jX2$]0"4 laf4yt5=pqr ,$IfgdJ( ,$IfgdJkd7|$$Ifl4֞h* N jX2$]0"4 laf4yt5=cgpqw}~  c "#$&c݃ރ߃&'()*+c jhzhJ5jwhzhJUjhzhJUhzhJ5\ hzhJPgp ,$IfgdJpqw}( ,$IfgdJkd}$$Ifl4֞h* N jX2$]0"4 laf4yt5=}~  ,$IfgdJ  ( ,$IfgdJkd}$$Ifl4֞h* N jX2$]0"4 laf4yt5= "#$&FfFfFf ,$IfgdJ ,$IfgdJ&( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=&'(+ ,$IfgdJ"+,-./QRSTUVcʅ˅̅ͅ΅υ+,289:<c݆hzhJB*phjhzhJU jhzhJ5j_hzhJUjhzhJUhzhJ5\ hzhJF( ,$IfgdJkdɈ$$Ifl4֞h* N jX2$]0"4 laf4yt5= ,$IfgdJ"+( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=+,-V ,$IfgdJ( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=υ+ ,$IfgdJ+,28( ,$IfgdJkd8$$Ifl4֞h* N jX2$]0"4 laf4yt5=89:< ,$IfgdJ( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=݆ ,$IfgdJ( ,$IfgdJkd΍$$Ifl4֞h* N jX2$]0"4 laf4yt5= !c#,-.0cirsyƈψЈшӈ `cijpyz{}hzhJ5\ jhzhJ jhzhJ5jhzhJUjhzhJUhzhJB*ph hzhJhzhJ5D  ,$IfgdJ#,( ,$IfgdJkd $$Ifl4֞h* N jX2$]0"4 laf4yt5=,-.0ir ,$IfgdJrsy( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5= ,$IfgdJƈψ( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=ψЈшӈ ,$IfgdJ ( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=`i ,$IfgdJijpy( ,$IfgdJkdL$$Ifl4֞h* N jX2$]0"4 laf4yt5=yz{}Ɖ ,$IfgdJƉlj͉։׉؉ډ!*+,.cktu{ӊ<JKQZ[\^c%&'()*c jhzhJ5jhzhJUjhzhJUhzhJ5\ hzhJNƉlj͉։( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=։׉؉ډ ,$IfgdJ!*( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=*+,.kt ,$IfgdJtu{( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=ӊ ,$IfgdJ( ,$IfgdJkdx$$Ifl4֞h* N jX2$]0"4 laf4yt5=<J ,$IfgdJJKQZ( ,$IfgdJkdC$$Ifl4֞h* N jX2$]0"4 laf4yt5=Z[\^ ,$IfgdJ( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5= ,$IfgdJ( ,$IfgdJkdٗ$$Ifl4֞h* N jX2$]0"4 laf4yt5=*iw ,$IfgdJcdiwx~ˌ̌Ҍی܌݌ߌ ()*,IRSYbcdfÍ͍̍΍Ѝ"+,2;<=?cwΎ׎؎ގhzhJ5\ hzhJhzhJh@Wwx~( ,$IfgdJkd+$$Ifl4֞h* N jX2$]0"4 laf4yt5=ˌ ,$IfgdJˌ̌Ҍی( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=ی܌݌ߌ  ,$IfgdJ(( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=()*,IR ,$IfgdJRSYb( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=bcdf ,$IfgdJ( ,$IfgdJkdW$$Ifl4֞h* N jX2$]0"4 laf4yt5= ,$IfgdJÍ̍( ,$IfgdJkd"$$Ifl4֞h* N jX2$]0"4 laf4yt5=͍̍΍Ѝ"+ ,$IfgdJ+,2;( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=;<=?w ,$IfgdJ( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=Ύ׎ ,$IfgdJ׎؎ގ( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=  ,$IfgdJ  "#$&cÏ̏͏ΏϏЏN\]cdgjklm +ззj6hzhJU jhzhJ5jhzhJUjhzhJUhzhJ5\ hzhJhzhJaJhzhJ^JaJ?"( ,$IfgdJkdN$$Ifl4֞h* N jX2$]0"4 laf4yt5="#$& ,$IfgdJÏ̏( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=̏͏ΏN\ ,$IfgdJ\]dg( ,$IfgdJkdk$$Ifl4֞h* N jX2$]0"4 laf4yt5=gjk ,$IfgdJ( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=0 ,$IfgdJ ,  $IfgdJ+,-./0cőƑǑȑɑʑ)78?EFGHIcklmnopϒВג   @ԼԮԠj~hzhJUj,hzhJUjڥhzhJUhzhJ5\ hzhJ jhzhJ5jhzhJUjhzhJU?( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=ʑ)7 ,$IfgdJ78?E( ,$IfgdJkda$$Ifl4֞h* N jX2$]0"4 laf4yt5=EFGpϒ ,$IfgdJϒВג( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5= @N ,$IfgdJ@NOVY\]^_c  @PQW]^_acqz{&'-01245chzhJH*hzhJB*ph jhzhJ jhzhJ5jЩhzhJUjhzhJUhzhJ5\ hzhJDNOVY( ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4yt5=Y\]  ,$IfgdJ  ( ,$IfgdJkdW$$Ifl4֞h* N jX2$]0"4 laf4yt5=@P ,$IfgdJPQW]( ,$IfgdJkd"$$Ifl4֞h* N jX2$]0"4 laf4yt5=]^_aqz ,$IfgdJz{# ,$IfgdJkd$$Ifl4֞h* N jX2$]0"4 laf4gyt5=& ,$IfgdJ&'-0( ,$IfgdJkd¬$$Ifl4֞h* N jX2$]0"4 laf4yt5=0124 ,$IfgdJ cЖіזݖcΗޗߗc 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laf4p(yt5=LMӠ-@ jeee```3gd5=gd5=|kdSE$$Ifl40N$$0$44 laf4yt5= ($IfgdJ $$IfgdJ1gd~A &5vvv 0$IfgdJjkdF$$Ifl44%|%0|%44 laf4yt5= 0$$IfgdJ1gd5=Vgd5= 56<" ,$IfgdJkdF$$Ifl44֞? M` %]NN0|%44 laf4yt5=<@CD ,$IfgdJDEʤʥͥΥԥڥۥ#$*.1589ʦ  ʧ˧̧ҧ֧٧ڧۧ;?AQZ[aehijȨʨ̨ΨިhzhJCJhzhJB*ph hzhJ jhzhJV$ ,$IfgdJkddG$$Ifl4֞? M` %]NN0|%44 laf4yt5=ͥ ,$IfgdJͥΥԥ$ ,$IfgdJkd!H$$Ifl4֞? M` %]NN0|%44 laf4yt5=ԥڥۥ# ,$IfgdJ#$kdH$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=$*.158  ,$IfgdJ  $ ,$IfgdJkdI$$Ifl4֞? M` %]NN0|%44 laf4yt5=˧ ,$IfgdJ˧̧ҧ$ ,$IfgdJkdJ$$Ifl4֞? M` %]NN0|%44 laf4yt5=ҧ֧٧ڧ;?AQZ ,$IfgdJZ[a$ ,$IfgdJkd@K$$Ifl4֞? M` %]NN0|%44 laf4yt5=aehiȨ̨Ψި ,$IfgdJ$ <<$IfgdJkdK$$Ifl4֞? M` %]NN0|%44 laf4yt5=| <<$IfgdJ|ʩptvʪΪЪ٪ڪ"&(128>?ȫʫ̫Ϋ׫ثޫ.24=>DJKvz|ʬѬլ׬hzhJB*ph hzhJhzhJCJhzhJB*CJphU$ ,$IfgdJkdL$$Ifl4֞? M` %]NN0|%44 laf4yt5=ptv ,$IfgdJ$ ,$IfgdJkdwM$$Ifl4֞? M` %]NN0|%44 laf4yt5=ʪΪЪ٪ ,$IfgdJ٪ڪkd4N$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ڪ"&(1 ,$IfgdJ12kdO$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=28>? ,$IfgdJkdP$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ȫ̫Ϋ׫ ,$IfgdJ׫ثkdP$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ثޫ.24= ,$IfgdJ=>kdQ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=>DJKvz| ,$IfgdJkdR$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=Ѭլ׬ ,$IfgdJkdS$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=KOQZ ,$IfgdJKOQZ[aghʭޭJNPYZ`fgɮʮͮϮخٮ߮W[]fgmstʯϯӯկޯ߯^bdmntz{ʰ ʱޱhzhJB*ph hzhJ\Z[kdT$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=[aghޭ ,$IfgdJkdtU$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=JNPY ,$IfgdJYZ kd\V$$Ifl4Z֞? M` %]NN0|%44 laf4p(yt5=Z`fgɮͮϮخ ,$IfgdJخٮkdHW$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ٮ߮W[]f ,$IfgdJfgkd0X$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=gmstϯӯկޯ ,$IfgdJޯ߯kdY$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=߯^bdm ,$IfgdJmnkdZ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ntz{ ,$IfgdJkdZ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=  ,$IfgdJkd[$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ޱ ,$IfgdJkd\$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ijmnopxyzʲݲimoxyʳ  ĴŴʴ{ʵGKMVW]cdʶ-13<=CIJhzhJB*ph hzhJhzhJhC.Zjnpy ,$IfgdJyzkd]$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=zݲ ,$IfgdJkd^$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=imox ,$IfgdJxykdp_$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=y ,$IfgdJkdX`$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=   ,$IfgdJkd@a$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ĴŴ{ ,$IfgdJkd(b$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=GKMV ,$IfgdJVWkdc$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=W]cd-13< ,$IfgdJ<=kdc$$Ifl4֞? M` %]NN0|%44 laf4p(yt5==CIJ ,$IfgdJƷʷ̷ͷ379BCIOPɸʸ͸ϸظٸ߸uy{ʹ%+,úĺʺIMOXY_efʻ  ʼ48:CDJhzhJB*ph hzhJ^kdd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=Ʒ̷ͷ379B ,$IfgdJBCkde$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=CIOPɸ͸ϸظ ,$IfgdJظٸkdf$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ٸ߸uy{ ,$IfgdJkdg$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkdh$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=%+, ,$IfgdJkdhi$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=úĺIMOX ,$IfgdJXYkdPj$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=Y_ef ,$IfgdJkd8k$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=   ,$IfgdJkd l$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=48:C ,$IfgdJCDkdm$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=DJPQ ,$IfgdJJPQʽ¾þʾbfhqrx~ʿ&'-34EIKTU[abVZ\eflrs hzhJB*ph hzhJ^kdm$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkdn$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=¾þbfhq ,$IfgdJqrkdo$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=rx~& ,$IfgdJ&'kdp$$Ifl4֞? M` %]NN0|%44 laf4p(yt5='-34 ,$IfgdJkdq$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=EIKT ,$IfgdJTUkdxr$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=U[ab ,$IfgdJkd`s$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=VZ\e ,$IfgdJefkdHt$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=flrs ,$IfgdJ kd0u$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=  ,$IfgdJ,02;<BEF=ACLMSYZFJLUV\bc NRT]^djkhzhJB*ph hzhJ^kdv$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=,02; ,$IfgdJ;<kdw$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=<BEF ,$IfgdJkdw$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkdx$$Ifl4֞? M` %]NN0|%44 laf4p(yt5==ACL ,$IfgdJLMkdy$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=MSYZ ,$IfgdJkdz$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd{$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=FJLU ,$IfgdJUVkdp|$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=V\bc ,$IfgdJkdX}$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd@~$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= NRT] ,$IfgdJ]^kd($$Ifl4֞? M` %]NN0|%44 laf4p(yt5=^djk ,$IfgdJ )*06748:CDJPQ:>@IJPVW  !VZ\efhzhJB*ph hzhJ^kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ) ,$IfgdJ)*kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=*067 ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkdȂ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=48:C ,$IfgdJCDkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=DJPQ ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJ$ ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4yt5=:>@I ,$IfgdJIJkd=$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=JPVW ,$IfgdJkd%$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=  ,$IfgdJkd $$Ifl4֞? M` %]NN0|%44 laf4p(yt5= !VZ\e ,$IfgdJefkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=flrs157@AGMN TXZcdjpq379BCIOP"#)/0hzhJB*ph hzhJ^flrs ,$IfgdJkd݉$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=157@ ,$IfgdJ@AkdŊ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=AGMN ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= TXZc ,$IfgdJcdkd}$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=djpq ,$IfgdJkde$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=379B ,$IfgdJBCkdM$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=CIOP ,$IfgdJkd5$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=" ,$IfgdJ"#kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=#)/0 ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=& ,$IfgdJ&'-34)-/89?EF CGIRSY_`'(.45!%'017= hzhJhzhJB*ph^&'kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5='-34 ,$IfgdJkdՓ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=)-/8 ,$IfgdJ89kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=9?EF ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJ$ ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4yt5= CGIR ,$IfgdJRSkdJ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=SY_` ,$IfgdJkd2$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=' ,$IfgdJ'(kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=(.45 ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=!%'0 ,$IfgdJ01kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=17=>  ,$IfgdJ=>  `dfopv|}"$-.4:;  Y]_hiouvTXZcdjpq"# hzhJhzhJB*ph^  kdқ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= `dfo ,$IfgdJopkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=pv|} ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5="$- ,$IfgdJ-.kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=.4:;  ,$IfgdJ  kdr$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= Y]_h ,$IfgdJhikdZ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=iouvTXZc ,$IfgdJcdkdB$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=djpq ,$IfgdJkd*$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=" ,$IfgdJ"#kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=#)/0$%+12osu~379BCIOP $&/06<= dhjstzhzhJB*ph hzhJ^#)/0 ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=$ ,$IfgdJ$%kdʥ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=%+12osu~ ,$IfgdJ~kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=379B ,$IfgdJBCkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=CIOP ,$IfgdJkdj$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= $&/ ,$IfgdJ/0kdR$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=06<= ,$IfgdJkd:$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd"$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= dhjs ,$IfgdJstkd $$Ifl4֞? M` %]NN0|%44 laf4p(yt5=tz ,$IfgdJ    BFHQRX[\%)+45;AB } hzhJhzhJB*ph^kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=   ,$IfgdJkdڮ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd¯$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=  ,$IfgdJ  kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= BFHQ ,$IfgdJQRkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=RX[\ ,$IfgdJkdz$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkdb$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=%)+4 ,$IfgdJ45kdJ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=5;AB ,$IfgdJkd2$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= } ,$IfgdJ dhjstz_cenou{|HLNWX^de?CENOU[\<hzhJB*ph hzhJ^kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= dhjs ,$IfgdJstkdҸ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=tz ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=_cen ,$IfgdJnokd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ou{| ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=HLNW ,$IfgdJWXkdr$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=X^de ,$IfgdJkdZ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=?CEN ,$IfgdJNOkdB$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=OU[\ ,$IfgdJkd*$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=<@BK ,$IfgdJ<@BKLRXY"&(128>? $&/069: "+,289 )*067hzhJB*ph hzhJ^KLkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=LRXY ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5="&(1 ,$IfgdJ12kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=28>? ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= $&/ ,$IfgdJ/0kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=069: ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= "+ ,$IfgdJ+,kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=,289 ,$IfgdJkdj$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ) ,$IfgdJ)*kdR$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=*067 ,$IfgdJkd:$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=' ,$IfgdJ'(.45Z^`ijpst!%'017=>RVXahzhJB*ph hzhJ^'(kd"$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=(.45 ,$IfgdJkd $$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=Z^`i ,$IfgdJijkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=jpst ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=!%'0 ,$IfgdJ01kdz$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=17=> ,$IfgdJkdb$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkdJ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=RVXa ,$IfgdJabhnoPTV_`flm &)*   !RVXhzhJB*ph hzhJ^abkd2$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=bhno ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=PTV_ ,$IfgdJ_`kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=`flm ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJ kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= &)* ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=   ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ! ,$IfgdJkdr$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkdZ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=RVXa ,$IfgdJXabhno!*+178`dfopv|}  !"bfhqrx~?CENOUhzhJB*ph hzhJ^abkdB$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=bhno ,$IfgdJkd*$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=!* ,$IfgdJ*+kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=+178 ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=`dfo ,$IfgdJopkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=pv|} ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=   ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=!"bfhq ,$IfgdJqrkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=rx~ ,$IfgdJkdj$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=?CEN ,$IfgdJNOkdR$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=OU[\ ,$IfgdJU[\%()rvx7;=M]^djk  "#\`bklrxyBFHQRX^_ jhzhJhzhJB*ph hzhJZkd:$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd"$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=%()rvx ,$IfgdJkd $$Ifl4֞? M` %]NN0|%44 laf4p(yt5=7;=M] ,$IfgdJ ]^d$ ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4yt5=djk ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=   ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5="#\`bk ,$IfgdJklkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=lrxy ,$IfgdJkdg$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=BFHQ ,$IfgdJQRkdO$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=RX^_ ,$IfgdJfjluv|<@BKLRXY"$-.4:;  %&hlnwx~hzhJB*ph hzhJ^kd7$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=fjlu ,$IfgdJuvkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=v| ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=<@BK ,$IfgdJKLkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=LRXY ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5="$- ,$IfgdJ-.kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=.4:; ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=   ,$IfgdJkdw$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=%&hlnw ,$IfgdJwxkd_$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=x~ ,$IfgdJ  PTV_`flmptv_cenou{|<@BKLRXY48:CDJPQhzhJB*ph hzhJ^kdG$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=  PTV_ ,$IfgdJ_`kd/$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=`flm ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ptv ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=_cen ,$IfgdJnokd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ou{| ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=<@BK ,$IfgdJKLkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=LRXY ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=48:C ,$IfgdJCDkdo$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=DJPQ ,$IfgdJ/35>?EKL                                                       hzhJB*ph hzhJ^kdW$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=/35> ,$IfgdJ>?kd?$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=?EKL ,$IfgdJkd'$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=     ,$IfgdJ  kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=         ,$IfgdJ  kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=         ,$IfgdJ  kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=         ,$IfgdJ  kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=         ,$IfgdJ  kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=     ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJ)-/89?EF|BFHQRX^_ $&/06<=EIKTU[abhzhJB*ph hzhJ^kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=)-/8 ,$IfgdJ89kdg$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=9?EF| ,$IfgdJkdO $$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd7 $$Ifl4֞? M` %]NN0|%44 laf4p(yt5=BFHQ ,$IfgdJQRkd $$Ifl4֞? M` %]NN0|%44 laf4p(yt5=RX^_ ,$IfgdJkd $$Ifl4֞? M` %]NN0|%44 laf4p(yt5= $&/ ,$IfgdJ/0kd $$Ifl4֞? M` %]NN0|%44 laf4p(yt5=06<= ,$IfgdJkd $$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=EIKT ,$IfgdJTUkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=U[ab ,$IfgdJ()/56nrt}~ "()cgirsy!"(./ptv!*+178khzhJB*ph hzhJ^kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=( ,$IfgdJ()kdw$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=)/56nrt} ,$IfgdJ}~kd_$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=~ ,$IfgdJkdG$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=  ,$IfgdJkd/$$Ifl4֞? M` %]NN0|%44 laf4p(yt5="()cgir ,$IfgdJrskd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=sy ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=! ,$IfgdJ!"kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5="(./ptv ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=!* ,$IfgdJ*+kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=+178koqz ,$IfgdJkoqz{"#)/0rvxUY[dekqr'+-67=CDSWYbciohzhJB*ph hzhJ^z{kd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5={ ,$IfgdJkdo$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=" ,$IfgdJ"#kdW$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=#)/0rvx ,$IfgdJkd?$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd'$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=UY[d ,$IfgdJdekd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ekqr ,$IfgdJkd$$Ifl4֞? M` %]NN0|%44 laf4p(yt5='+-6 ,$IfgdJ67kd $$Ifl4֞? M` %]NN0|%44 laf4p(yt5=7=CD ,$IfgdJkd!$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd"$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=SWYb ,$IfgdJbckd#$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=ciop ,$IfgdJop%)+45;AB.24=>DGHKOQZ[`abhihzhJH* hzhJhzhJB*phZkd$$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=%)+4 ,$IfgdJ45kdg%$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=5;AB ,$IfgdJkdO&$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd7'$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=.24= ,$IfgdJ=>kd($$Ifl4֞? M` %]NN0|%44 laf4p(yt5=>DGH ,$IfgdJkd)$$Ifl4֞? M` %]NN0|%44 laf4p(yt5= ,$IfgdJkd)$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=KOQZ ,$IfgdJZ[kd*$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=[bhi ,$IfgdJkd+$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=EIKT ,$IfgdJEIKTUZ[\bc!*+145  $ ( * 3 4 : = >          !!! !!!! !#!$!!!!!!!!!!""$"("*"3"4":"@"hzhJH* hzhJhzhJB*phZTUkd,$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=U\bc ,$IfgdJkd-$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=!* ,$IfgdJ*+kdw.$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=+145 ,$IfgdJkd_/$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=$ ( * 3  ,$IfgdJ3 4 kdG0$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=4 : = >      ,$IfgdJ  kd/1$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=    ! !!! ,$IfgdJ!!kd2$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=! !#!$!!!!! ,$IfgdJ!!kd2$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=!!!!$"("*"3" ,$IfgdJ3"4"kd3$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=4":"@"A"n"r"t"}" ,$IfgdJ@"A"n"r"t"}"~""""""""""""""##u#y#{###############$$$"$$$-$.$4$:$;$$$$$$$$$$%%?%C%E%N%O%U%[%\%%%%%%%%%%&&7&;&=&F&G&N&T&U&&'''''&''' hzhJhzhJB*ph^}"~"kd4$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=~"""""""" ,$IfgdJ""kd5$$Ifl4֞? M` %]NN0|%44 laf4p(yt5="""""u#y#{## ,$IfgdJ##kd6$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=######## ,$IfgdJ##kd7$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=####$"$$$-$ ,$IfgdJ-$.$kdo8$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=.$4$:$;$$$$$ ,$IfgdJ$$kdW9$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=$$$$?%C%E%N% ,$IfgdJN%O%kd?:$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=O%U%[%\%%%%% ,$IfgdJ%%kd';$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=%%%%7&;&=&F& ,$IfgdJF&G&kd<$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=G&N&T&U&'''&' ,$IfgdJ&'''kd<$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=''.'4'5''(((((((((((((((((()))))))))))***********+++++++++++,,,,,,,,,,,-----------...........//////hzhJB*ph hzhJ^''.'4'5'(((( ,$IfgdJ((kd=$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=(((((((( ,$IfgdJ((kd>$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=(((()))) ,$IfgdJ))kd?$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=))))**** ,$IfgdJ**kd@$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=****++++ ,$IfgdJ++kdA$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=++++,,,, ,$IfgdJ,,kdgB$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=,,,,---- ,$IfgdJ--kdOC$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=----.... ,$IfgdJ..kd7D$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=....//// ,$IfgdJ//////00000000111 1 1122222!2"2'2(2*20212h2l2n2w2x2}2~22222222222233333'3(3/35363n3r3t3}3~3333333333333444 4"4+4,43494:4x4|4~444hzhJH*hzhJB*ph hzhJ[//kdE$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=////0000 ,$IfgdJ00kdF$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=01 1 1222!2 ,$IfgdJ!2"2kdF$$Ifl4֞? M` %]NN0|%44 laf4p(yt5="2*20212h2l2n2w2 ,$IfgdJw2x2kdG$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=x22222222 ,$IfgdJ22kdH$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=2222333'3 ,$IfgdJ'3(3kdI$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=(3/35363n3r3t3}3 ,$IfgdJ}3~3kdJ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=~33333333 ,$IfgdJ33kdwK$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=33334 4"4+4 ,$IfgdJ+4,4kd_L$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=,43494:4x4|4~44 ,$IfgdJ44kdGM$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=444444444444455=5A5E5N5O5U5X5Y5555555556666"6+6,63696:6g6k6m6v6w6~666666666666667777 777A7E7G7P7Q7X7^7_7777777777777777777hzhJB*ph hzhJ\44444444 ,$IfgdJ44kd/N$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=4444=5A5E5N5 ,$IfgdJN5O5kdO$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=O5U5X5Y55555 ,$IfgdJ55kdO$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=555566"6+6 ,$IfgdJ+6,6kdP$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=,63696:6g6k6m6v6 ,$IfgdJv6w6kdQ$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=w6~6666666 ,$IfgdJ66kdR$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=66666667 ,$IfgdJ77kdS$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=7 777A7E7G7P7 ,$IfgdJP7Q7kdT$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=Q7X7^7_77777 ,$IfgdJ77kdoU$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=77777777 ,$IfgdJ77kdWV$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=7777788888 ,$IfgdJ 77888888888888888999!9#939<9=9C9G9J9K9L999999999999::8:<:>:N:W:X:^:d:e::::::::::::::::::;;-;1;3;<;=;C;I;J;m;q;s;|;};;;;;;;;hzhJB*ph hzhJ jhzhJZ888$ ,$IfgdJkd?W$$Ifl4֞? M` %]NN0|%44 laf4yt5=888889!9#939<9 ,$IfgdJ <9=9C9$ ,$IfgdJkdW$$Ifl4֞? M` %]NN0|%44 laf4yt5=C9G9J9K999999 ,$IfgdJ999$ ,$IfgdJkdX$$Ifl4֞? M` %]NN0|%44 laf4yt5=99998:<:>:N:W: ,$IfgdJW:X:^:$ ,$IfgdJkdvY$$Ifl4֞? M` %]NN0|%44 laf4yt5=^:d:e::::: ,$IfgdJ::kd3Z$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=:::::::: ,$IfgdJ::kd[$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=::::-;1;3;<; ,$IfgdJ<;=;kd\$$Ifl4֞? M` %]NN0|%44 laf4p(yt5==;C;I;J;m;q;s;|; ,$IfgdJ|;};kd\$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=};;;;;;;; ,$IfgdJ;;;;;;<< < <<<<<%<&<R<V<X<a<b<h<n<o<<<<<<<<<<<<<<<<<<=====$=%=+=1=2=_=c=e=n=o=u={=|==================>>">&>(>1>2>8>;><>>>>>>>>>>hzhJB*ph hzhJ^;;kd]$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=;;;; < <<< ,$IfgdJ<<kd^$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=<<%<&<R<V<X<a< ,$IfgdJa<b<kd_$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=b<h<n<o<<<<< ,$IfgdJ<<kd`$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=<<<<<<<< ,$IfgdJ<<kdsa$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=<<<<===$= ,$IfgdJ$=%=kd[b$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=%=+=1=2=_=c=e=n= ,$IfgdJn=o=kdCc$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=o=u={=|===== ,$IfgdJ==kd+d$$Ifl4֞? M` %]NN0|%44 laf4p(yt5========= ,$IfgdJ==kde$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=====">&>(>1> ,$IfgdJ1>2>kde$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=2>8>;><>>>>> ,$IfgdJ>>kdf$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=>>>>>>>> ,$IfgdJ>>>>>>>>>??,?0?2?;?AGAHANARAUAVAWAABBBBBB(B)B/B5B jhzhJhzhJB*ph hzhJZ>>kdg$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=>>>>,?0?2?;? ,$IfgdJ;?AGA ,$IfgdJGAHAkd o$$Ifl4֞? M` %]NN0|%44 laf4p(yt5=HANARAUAVABBBB(B ,$IfgdJ (B)B/B$ ,$IfgdJkdo$$Ifl4֞? M` %]NN0|%44 laf4yt5=/B5B6BRBVBXBaB ,$IfgdJ5B6BRBVBXBaBbBhBnBoBBBBBBBBBBBBBBBBBBCCCCCCCCCCCDDD D DDD#D&D'DGDKDMDVDWD]D`DaDDDDDDDDDDDDDDDDDDEEEEEEEEEFEJELEUEVEWE^Ehzh;hhzhJmH sH  hzhJXaBbBkdp$$Ifl4֞? 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saf4ytrwlllxmul ,$Ifgdrw,$If^`gdrwykdB$$Ifs40h($Q o0"64 saf4ytrwxmymmmul ,$Ifgdrw,%$If^`%gdrwykdC$$Ifs40h($Q o0"64 saf4ytrwmmmmul ,$Ifgdrw %$If^`%gdrwykdSD$$Ifs40h($Q o0"64 saf4ytrwmmm=nSnjnnpulllll ,$Ifgdrw %$If^`%gdrwykdE$$Ifs40h($Q o0"64 saf4ytrwn=nSnjn|nnnnoo|ooopppp1p2pEp|pppqq;q?@|y|Ϙ|˙̙͙ՙ֙ۙ0R|˚ɻܨ$j( hzhRCJUmHnHuhzhRCJmHnHu$jhzhRCJUmHnHuhzhRCJhzhR6]hzhR5\ hzhRB?@yϘ0RG!,-/0b̠֠נ٠ڠgd + hx<^hgd +gd +h^hgd +z{|˛G]|˜|˝NOP|˞!",-./0b|˟|ǾhzhR5\hzhRCJmHnHu$j hzhRCJUmHnHuhzhRCJhzhR6]hzhR6hzhR6B*phhzhR>*hzhR^JaJ hzhR:ˠ̠֠נؠ٠ڠ|ˡ|ˢ|ʣˣ|ˤ|¥)*|¦|§ops³³hzho\hzhoB* ^JaJph3 hzhohzhR5\$j ThzhRCJUmHnHuhzhRCJhzhR6] hzhRBʣ¥*je`gdogdoykd$$Ifl40N$$0$64 laf4yto ($Ifgdo $IfgdogdRgd + pv!v!!!w!!!!!!e`gdOykd_$$Ifl40N$$0$64 laf4yt# ($IfgdO $IfgdOgdo gdogdo s|¨Ũvy!!!!!!v!y!!!!!!!!!w!!!!! ! ! ! !!!!!!!!!!!!!"!"!#!>#!#!$!$!$!$!$!$!$!$!$!$!$!$!$!$!$!$!$!$!$!$!$!jh Uh h6jh6Uh`t hzh`thzhOmH sH  hzhOhzho5U hzhohzho5\E: Multi-use vials are not subject to payment for any discarded amounts of the drug. The units billed must correspond with the units administered to the beneficiary. 3. Documentation: The provider must clearly document in the patients medical record the actual dose administered in addition to the exact amount wasted and the total amount the vial is labeled to contain. 4. Paper Billing: For drug HCPCS/CPT codes requiring paper billing (i.e., for manual review), complete every field of the DMS-664 Procedure Code/NDC Detail Attachment Form. Attach this form and any other required documents to your claim when submitting it for processing. Remember to verify the milligrams given to the patient and then convert to the proper units for billing. Follow the Centers for Disease Control (CDC) requirements for safe practices regarding expiration and sterility of multi-use vials. 242.410 Completion of Form - Medicare/Medicaid Deductible And Coinsurance10-13-03If the Medicare fiscal intermediary is Arkansas Blue Cross/Blue Shield, the claim should be filed according to Medicares instructions and sent to the Medicare intermediary. The Medicaid provider number and the beneficiary ID number must be entered in Field 9 on the claim form. The claim will automatically cross to Medicaid. If Medicaid reimbursement has not been received within six weeks after receiving Medicare payment, refer to Section 302.100. 242.420 Freight Charges, All Ages10-13-03Providers may include the freight charge on claims submitted to the Arkansas Medicaid Program for manual pricing and reimbursement of prosthetics services. If the freight charge is reflected as a charge on the manufacturers invoice, this will provide necessary documentation. However, if there is a separate freight invoice, the freight invoice must also be attached to the claim. When a provider has ordered several items and is submitting a claim to the Medicaid Program for only certain items included on the invoice, the provider must determine and indicate on the invoice, the freight charges for those items being billed to Medicaid. Only the freight charge incurred for the covered Medicaid items may be included on the Medicaid claim.     Prosthetics Section II Section II- PAGE 158 Bill on paper (Indicate specific name of formula on claims.) 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