ARKids First-B Section II - Arkansas

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|Section II - ARKids First - B | |

|CONTENTS | |

200.000 ARKIDS FIRST-B GENERAL INFORMATION

200.100 Introduction

200.110 ARKids First-A and ARKids First-B

200.200 Eligibility

200.300 ARKids First-B Identification Card

200.310 When a Beneficiary’s ARKids First Eligibility Changes

200.320 Provider Verification of Eligibility

200.330 ARKids First ID Card Example

200.340 Non-Receipt or Loss of ID Card

201.000 Electronic Signatures

210.000 PROGRAM POLICY

211.000 Provider Participation Requirements

220.000 COVERAGE

221.000 Scope

221.100 ARKids First-B Medical Care Benefits

221.200 Exclusions

222.000 Benefits - ARKids First-B Program

222.100 Medical Supplies Benefit

222.200 Durable Medical Equipment (DME) Benefit

222.300 Dental Services Benefit

222.400 Vision Care Benefit Limit

222.500 Home Health Benefit

222.600 Occupational, Physical, and Speech-Language Therapy Benefits

222.700 Preventive Health Screens

222.710 Introduction

222.720 Hearing Screens

222.730 Vision Screens

222.740 Preventive Dental Screens

222.750 Health Education

222.800 Schedule for Preventive Health Screens

222.810 Newborn Screen (Ages 3 to 5 Days)

222.820 Infancy (Ages 1–9 Months)

222.830 Early Childhood (Ages 12 Months–4 Years)

222.840 Middle Childhood (Ages 5 - 10 Years)

222.850 Adolescence (Ages 11 - 18 Years)

222.900 Substance Abuse Treatment Services

223.000 Extended Benefits

223.100 Medical Supplies Extended Benefits

223.200 Occupational, Physical and Speech Therapy Extended Benefits

224.000 Cost Sharing

224.100 Co-payment

224.200 Co-insurance

224.210 Durable Medical Equipment Co-insurance

224.220 Inpatient Hospital Co-Insurance

240.000 PRIOR AUTHORIZATION

240.050 Prior Authorization (PA) Procedures

240.100 Inpatient Hospital Medicaid Utilization Management Program (MUMP)

240.200 Prior Authorization (PA) Process for Interperiodic Preventive Dental Screens

240.300 Prior Authorization (PA) for Outpatient and Inpatient Mental Health Services

240.400 Prior Authorization for Other Services

241.000 Beneficiary or Provider Appeal Process

250.000 REIMBURSEMENT

250.010 Reimbursement Introduction

250.020 Fee Schedules

260.000 BILLING Procedures

261.000 Introduction to Billing

261.100 Timely Filing

262.000 ARKids First-B Billing Procedures

262.100 CPT and/or HCPCS Procedure Codes

262.110 Medical Supplies Procedure Codes

262.120 Durable Medical Equipment (DME) Procedure Codes

262.130 Preventive Health Screening Procedure Codes

262.140 Speech-Language Pathology, Occupational, and Physical Therapy Procedure Codes

262.141 Occupational, Physical, and Speech-Language Pathology Therapy Procedure Codes

262.150 Billing Procedure Codes for Periodic Dental Screens and Services and Orthodontia Services

262.200 National Place of Service Codes

262.300 Billing Instructions – Paper Claims Only

262.400 Billing Procedures for Preventive Health Screens

262.410 Primary Care Physician Referral Requirements for Preventive Health Screens

262.420 Limitation on Laboratory Procedures Performed During a Preventive Health Screen

262.430 Vaccines for ARKids First-B Beneficiaries

262.431 Billing of Multi-Use and Single-Use Vials

|200.000 arkids first-b GENERAL INFORMATION | |

|200.100 Introduction |2-1-10 |

Act 407 of 1997 established the ARKids First-B Program to extend health care coverage to Arkansas’ uninsured children. The ARKids First-B Program integrates uninsured children into the health care system with benefits comparable to the state employees/teachers insurance program.

ConnectCare is the Primary Care Physician Managed Care Program utilized by the Arkansas Medicaid Program for the ARKids First-B Program. ARKids First-B providers must be enrolled in the Arkansas Medicaid Program and are bound by all policies and regulations in their respective Arkansas Medicaid provider manual, in addition to the policies and regulations of the ARKids First-B Program.

|200.110 ARKids First-A and ARKids First-B |7-1-20 |

Medicaid-eligible children in the SOBRA eligibility category for pregnant women, infants, and children (category 61 PW-PL) and newborn children born to Medicaid-eligible mothers (categories 52 and 63), are known as ARKids First-A beneficiaries. Un-insured, non Medicaid-eligible children that meet additional established eligibility requirements will have health coverage under ARKids First-B, a CHIP separate child health program. All ARKids First beneficiaries will receive a program identification card without indication of level of coverage (either ARKids First-A or ARKids First-B).

A Medicaid eligibility verification transaction response either through the provider portal via the web or through the Voice Response System (VRS) will indicate that the individual is either an ARKids First-A beneficiary or an ARKids First-B beneficiary. The response will also indicate that cost sharing may be required for ARKids First-B beneficiaries. Refer to Section I of the Arkansas Medicaid provider manual for automated eligibility verification procedures.

When a child presents as an ARKids First-A eligible beneficiary, the provider must refer to the regular Medicaid provider policy manuals. When an ARKids First-B eligible beneficiary is identified, the provider must refer to the ARKids First-B Provider Manual for determination of levels of coverage, as well as the associated Medicaid provider policy manuals for the services provided.

|200.200 Eligibility |7-1-20 |

Eligibility criteria for ARKids First-B are:

A. Family income must be above 142% and not exceed 211% plus five-percent (5%) disregard (216%) of the federal poverty level;

B. Applicants must be age eighteen (18) and under;

C. Applicants must have had no health insurance that covers comprehensive medical services, other than Medicaid, within the preceding ninety (90) days (unless insurance coverage was lost through no fault of the applicant);

D. Applicants whose health insurance is inaccessible are considered uninsured. An example of “inaccessible” is when an out of state, non-custodial parent, has HMO insurance for his or her children but the HMO network does not contain medical providers where the children reside; and

E. Children who do not have primary comprehensive health insurance or have non-group or non-employer-sponsored insurance, are considered to be uninsured. Primary comprehensive health insurance is defined as insurance that covers both physician and hospital charges.

An application must be completed by the applicant or family. Application forms are available at local Department of Human Services (DHS) county offices, Arkansas Department of Health local health units, churches, licensed day care centers, hospitals, selected physician offices and clinics, public schools, community and neighborhood centers, and pharmacies. Applicants may call the ARKids First-B toll free number or complete an online request by visiting the Arkansas Medicaid website to have an application mailed to them. View or print the ARKids First-B telephone number.

The State has assigned Aid Category 01 to ARKids First-B beneficiaries. The Aid Category Description for ARKids First-B beneficiaries is AK.

A Medicaid eligibility verification transaction response either through the provider portal via the web or through the Voice Response System (VRS) will indicate that the individual is an ARKids First-B beneficiary. The response will also indicate that cost sharing may be required. Refer to Section I of the Arkansas Medicaid provider manual for automated eligibility verification procedures.

|200.300 ARKids First-B Identification Card |2-1-10 |

When eligibility is established, an ARKids First beneficiary receives an identification (ID) card for eligibility verification. New beneficiaries, in both the ARKids First-A and the ARKids First-B Programs, will be issued a generic ARKids First ID card. The card will not identify the beneficiary’s program as an ARKids First-A, nor an ARKids First-B. The ID card beneficiary identification number will indicate the A or B status for an ARKids First beneficiary when the provider verifies eligibility at the time of each visit.

|200.310 When a Beneficiary’s ARKids First Eligibility Changes |2-1-10 |

The beneficiary’s Medicaid ID number will not change when he or she moves from A to B or from B to A within the ARKids First umbrella program. The beneficiary will not be issued a new card when the change occurs. Existing ID cards will not be replaced, so it will not be possible for a provider to determine by viewing the ID card whether payment is eligible in the ARKids First-B program that requires additional cost-sharing or the ARKids First-A program.

|200.320 Provider Verification of Eligibility |7-1-20 |

The ARKids First identification card does not guarantee an individual’s eligibility. Payment is subject to verification that the beneficiary is eligible at the time services are provided. It is crucial to the provider that eligibility is determined at each visit.

Eligibility verification transactions may be made through the provider portal via the web or through the Voice Response System (VRS). Refer to Section I of the Arkansas Medicaid provider manual for automated eligibility verification procedures.

|200.330 ARKids First ID Card Example |7-1-04 |

View or print the ARKids First ID card example.

|200.340 Non-Receipt or Loss of ID Card |2-1-10 |

When ARKids First-B beneficiaries report non-receipt or loss of an ID card, refer the beneficiary to the DHS County Office or the Division of County Operations, Customer Assistance. View or print the Division of County Operations - Customer Assistance Section Contact Information.

|201.000 Electronic Signatures |10-8-10 |

Medicaid will accept electronic signatures provided the electronic signature complies with the Arkansas Code § 25-31-103 et seq.

|210.000 PROGRAM POLICY | |

|211.000 Provider Participation Requirements |11-1-06 |

ARKids First-B providers must meet the Provider Participation and enrollment requirements contained within Section 140.000 of this manual. Refer to Section II of the appropriate provider manual for additional provider participation requirements.

The ARKids First-B Provider Manual is supplied to indicate the services available to beneficiaries in the ARKids First-B Waiver Program, with some differences in requirements from the services available to the regular Medicaid population. If a service is not addressed in this manual, the information supplied in the appropriate provider manual applies.

|220.000 COVERAGE | |

|221.000 Scope |4-1-09 |

Covered services provided to ARKids First-B beneficiaries are within the same scope of services provided to Arkansas Medicaid ARKids First –A beneficiaries. However, some services are subject to different levels of benefits and cost sharing amounts are applied. Refer to the appropriate Arkansas Medicaid provider manual for the scope of each service covered under the ARKids First Program. See Section 221.100 of this manual for a listing of ARKids First-B Medical Care Benefits that indicate restrictions and required co-payment/co-insurance or cost-sharing amounts for covered services.

ARKids First-B beneficiaries receive preventive health care screens and treatment options within covered benefits. ARKids First-B beneficiaries are not entitled to the same benefits as children under the Arkansas Medicaid Child Health Services (EPSDT) Program and may not be billed as an EPSDT screen.

|221.100 ARKids First-B Medical Care Benefits |1-1-21 |

Listed below are the covered services for the ARKids First-B program. This chart also includes benefits, whether Prior Authorization or a Primary Care Physician (PCP) referral is required, and specifies the cost-sharing requirements.

|Program Services |Benefit Coverage and Restrictions |Prior Authorization/ PCP |Co-payment/ Coinsurance/ |

| | |Referral* |Cost Sharing Requirement**|

|Ambulance |Medical Necessity |None |$10 per trip |

|(Emergency Only) | | | |

|Ambulatory Surgical Center |Medical Necessity |PCP Referral |$10 per visit |

|Audiological Services (only |Medical Necessity |None |None |

|Tympanometry, CPT procedure code| | | |

|92567, when the diagnosis is | | | |

|within the ICD range (View ICD | | | |

|codes.)) | | | |

|Certified Nurse-Midwife |Medical Necessity |PCP Referral |$10 per visit |

|Chiropractor |Medical Necessity |PCP Referral |$10 per visit |

|Dental Care |Routine dental care and orthodontia |None – PA for inter-periodic |$10 per visit |

| |services |screens and orthodontia | |

| | |services | |

|Durable Medical Equipment |Medical Necessity |PCP Referral and Prescription |10% of Medicaid allowed |

| |$500 per state fiscal year (July 1 | |amount per DME item |

| |through June 30) minus the | |cost-share |

| |coinsurance/cost-share. Covered items | | |

| |are listed in Section 262.120 | | |

|Emergency Dept. Services | | |

|Emergency |Medical Necessity |None |$10 per visit |

|Non-Emergency |Medical Necessity |PCP Referral |$10 per visit |

|Assessment |Medical Necessity |None |$10 per visit |

|Family Planning |Medical Necessity |None |None |

|Federally Qualified Health |Medical Necessity |PCP Referral |$10 per visit |

|Center (FQHC) | | | |

|Home Health |Medical Necessity |PCP Referral |$10 per visit |

| |(10 visits per state fiscal year (July 1| | |

| |through June 30) | | |

|Hospital, Inpatient |Medical Necessity |PA on stays over 4 days if age |10% of first inpatient day|

| | |1 or over | |

|Hospital, Outpatient |Medical Necessity |PCP referral |$10 per visit |

|Inpatient Psychiatric Hospital |Medical Necessity |PA & Certification of Need is |10% of first inpatient day|

|and Psychiatric Residential | |required prior to admittance | |

|Treatment Facility | | | |

|Immunizations |All per protocol |None |None |

|Laboratory & X-Ray |Medical Necessity |PCP Referral |$10 per visit |

|Medical Supplies |Medical Necessity |PCP Prescriptions |None |

| |Benefit of $125/mo. Covered supplies |PA required on supply amounts | |

| |listed in Section 262.110 |exceeding $125/mo | |

|Mental and Behavioral Health, |Medical Necessity |PCP Referral |$10 per visit |

|Outpatient | |PA on treatment services | |

|School-Based Mental Health | |PA Required (See Section | |

| |Medical Necessity |250.000 of the School-Based |$10 per visit |

| | |Mental Health provider manual.)| |

|Nurse Practitioner |Medical Necessity |PCP Referral |$10 per visit |

|Physician |Medical Necessity |PCP referral to specialist and |$10 per visit |

| | |inpatient professional services| |

|Podiatry |Medical Necessity |PCP Referral |$10 per visit |

|Prenatal Care |Medical Necessity |None |None |

|Prescription Drugs |Medical Necessity |Prescription |Up to $5 per prescription |

| | | |(Must use generic, if |

| | | |available)*** |

|Preventive Health Screenings |All per protocol |PCP Administration or PCP |None |

| | |Referral | |

|Rural Health Clinic |Medical Necessity |PCP Referral |$10 per visit |

|Speech-Language Therapy |Medical Necessity |PCP Referral |$10 per visit |

| |4 evaluation units (1 unit =30 min) per |Authorization required on | |

| |state fiscal year |extended benefit of services | |

| |4 therapy units (1 unit=15 min) daily | | |

|Occupational Therapy |Medical Necessity |PCP Referral |$10 per visit |

| |2 evaluation units per state fiscal year|Authorization required on | |

| | |extended benefit of services | |

|Physical Therapy |Medical Necessity |PCP Referral |$10 per visit |

| |2 evaluation units per state fiscal year|Authorization required on | |

| | |extended benefit of services | |

|Vision Care | | |

|Eye Exam |One (1) routine eye exam (refraction) |None |$10 per visit |

| |every 12 months | | |

|Eyeglasses |One (1) pair every 12 months |None |None |

*Refer to your Arkansas Medicaid specialty provider manual for prior authorization and PCP referral procedures.

**ARKids First-B beneficiary cost-sharing is capped at 5% of the family’s gross annual income.

***ARKids First-B beneficiaries will pay a maximum of $5.00 per prescription. The beneficiary will pay the provider the amount of co-payment that the provider charges non-Medicaid purchasers up to $5.00 per prescription.

|221.200 Exclusions |7-1-20 |

Services Not Covered for ARKids First-B Beneficiaries:

Adult Development Day Treatment (ADDT)

Audiological Services; EXCEPTION, Tympanometry, CPT procedure code 92567, when the diagnosis is within the ICD range. (View ICD codes.)

Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Diapers, Underpads, and Incontinence Supplies

Early Intervention Day Treatment (EIDT)

End Stage Renal Disease Services

Hearing Aids

Hospice

Hyperalimentation

Non-Emergency Transportation

Nursing Facilities

Orthotic Appliances and Prosthetic Devices

Personal Care

Private Duty Nursing Services

Rehabilitative Services for Children

Rehabilitative Services for Persons with Physical Disabilities (RSPD)

Targeted Case Management

Ventilator Services

|222.000 Benefits - ARKids First-B Program | |

|222.100 Medical Supplies Benefit |4-1-09 |

Only Prosthetics Program and Home Health Program providers may bill for items in the medical supplies category. Refer to Section 262.110 of this manual for a listing of medical supplies covered for ARKids First-B beneficiaries. Medical supplies benefits are $125.00 per month, per beneficiary. The $125.00 may be provided by the Home Health Program, the Prosthetics Program or a combination of the two. However, an ARKids First-B beneficiary may not receive more than a total of $125.00 of supplies per month unless extended benefits have been requested and granted. An extension of the $125.00 per month benefit may be considered when medically necessary. Refer to the respective Arkansas Medicaid Provider Manual for procedures regarding requests for extended benefits for medical supplies.

|222.200 Durable Medical Equipment (DME) Benefit |7-1-11 |

Durable Medical Equipment (DME) benefit for ARKids First-B beneficiaries is $500.00 per state fiscal year (July 1 through June 30). There is a 10% co-insurance per item. DME may be billed by providers enrolled in the Prosthetics Program.

Refer to Section 262.120 of this manual for a listing of DME items covered by the ARKids First-B Program.

|222.300 Dental Services Benefit |8-1-15 |

Dental services benefits for ARKids First-B beneficiaries are one periodic dental exam, bite-wing x-rays, and prophylaxis/fluoride treatments every six (6) months plus one (1) day. Scalings are covered once per State Fiscal Year (SFY). Orthodontia services are also covered for ARKids First-B beneficiaries.

The procedure codes listed in Section 262.150 may be billed for the periodic dental exams, interperiodic dental exams and prophylaxis/fluoride, and orthodontia services for ARKids First–B beneficiaries.

Refer to Section II of the Medicaid Dental Provider Manual for a complete listing of covered dental and orthodontia services. Procedures for dental treatment services that are not listed as a payable service in the Medicaid Dental Provider Manual may be requested on individual treatment plans for prior authorization review. These individually requested procedures and dental and orthodontia treatment services are subject to determination of medical necessity, review and approval by the Division of Medical Services dental consultants.

|222.400 Vision Care Benefit Limit |4-1-09 |

One routine eye exam (refraction) every twelve months is covered for ARKids First-B beneficiaries.

Refer to Section II of the Visual Care Provider Manual for a complete listing of covered visual services.

|222.500 Home Health Benefit |4-1-09 |

Home Health benefits for ARKids First-B beneficiaries are 10 visits per state fiscal year (July 1 through June 30). The 10 visits may be provided by a registered nurse or licensed practical nurse or a combination of the two. However, an ARKids First-B beneficiary will not have coverage for more than 10 visits per state fiscal year.

Refer to Section II of the Home Health Provider manual for further coverage details and billing procedures.

See Section 222.100 regarding benefits for medical supplies.

|222.600 Occupational, Physical, and Speech-Language Therapy Benefits |1-1-21 |

Occupational, physical, and speech-language therapy services are available to beneficiaries in the ARKids First-B program and must be performed by a qualified, Medicaid participating Occupational, Physical, or Speech-Language Therapist. A referral for an occupational, physical, or speech-language therapy evaluation and prescribed treatment must be made by the beneficiary’s PCP or attending physician if exempt from the PCP program. All therapy services for ARKids First–B beneficiaries require referrals and prescriptions be made utilizing the “Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21” form DMS-640. View or print form DMS-640.

Occupational, physical, and speech-language therapy referrals and covered services are further defined in the Physicians and in the Occupational, Physical, and Speech-Language Therapy Provider Manuals. Physicians and therapists must refer to those manuals for additional rules and regulations that apply to occupational, physical, or speech-language therapy services for ARKids First–B beneficiaries.

ARKids First-B has the same occupational, physical, and speech-language therapy services benefits as Arkansas Medicaid, which are found in the procedure codes for therapy services. View or print the procedure codes for therapy services.

All requests for extended therapy services must comply with the guidelines located within the Occupational, Physical, and Speech-Language Therapy Provider Manual.

|222.700 Preventive Health Screens | |

|222.710 Introduction |4-1-09 |

The ARKids First-B Program supports preventive medicine for beneficiaries by reimbursing primary care physicians (PCPs) who provide medical preventive health screens and qualified screening providers to whom PCPs refer beneficiaries. ARKids First-B outreach efforts vigorously promote the program’s emphasis on preventive medical health care. Beneficiary cost sharing does not apply to covered preventive medical health screens, including those for newborns.

The supplemental eligibility response request to an ARKids First-B beneficiary’s identification card will indicate to the provider the date of the beneficiary’s last preventive health screen (procedure codes 99381 through 99385; and/or 99391 through 99395). This information should be reviewed and verified, along with the beneficiary’s eligibility, prior to performing a service. This information will assist the beneficiary’s PCP or preventive health screen provider in determining the beneficiary’s eligibility for the service and ensuring that preventive health screens are performed in a timely manner in compliance with the periodicity chart for ARKids First-B beneficiaries.

Newborn screens do not require PCP referral.

Certified nurse-midwives may provide newborn screens ONLY.

Nurse practitioners, in addition to newborn preventive health screens, are authorized to provide other preventive health screens with a PCP referral. Refer to Section 262.130 for preventive health screens procedure codes.

|222.720 Hearing Screens |4-1-09 |

A hearing risk assessment is required for all children receiving a periodic complete medical preventive health screen. Medical screening providers must administer an age-appropriate hearing assessment. The age-specific procedures (Sections 222.810 – 222.850) may be helpful to determine the necessary procedures according to the child’s age. Consult with audiologists or the Department of Education to obtain appropriate procedures to use for screening and methods of administering the risk assessment screens. This screening does not require machine audiology testing. Subjective testing may be provided as part of a hearing screening.

|222.730 Vision Screens |4-1-09 |

A vision risk assessment is required for all children receiving a complete medical preventive health screen. The age-specific procedures (Sections 222.810 – 222.850) may be helpful to determine the necessary procedures according to the child’s age. This screening does not require Titmus machine or other ophthalmological testing. Subjective testing may be provided as part of a vision screening. However, a vision risk assessment does not substitute for a full periodic preventive vision screen through a Medicaid participating vision provider.

A full annual vision screening by a Medicaid participating vision provider is exempt from the PCP referral requirement (see Section 222.400). When a full annual vision periodicity schedule screen coincides with the schedule for a periodic complete medical preventive health screen, the different screens may not be performed on the same day, or within seven (7) days of each other without claim denial citing duplication of services.

|222.740 Preventive Dental Screens |4-1-09 |

An oral assessment is considered part of the complete medical preventive health screen; however, an oral assessment may not substitute for a full periodic preventive dental examination through a Medicaid dental provider. Assistance with establishing a dental home for the beneficiary is included as part of the medical screen. A PCP referral is not required for dental services provided by a Medicaid participating dentist; see Section 222.300 for further details on the dental services available to ARKids First – B beneficiaries. See Section 262.150 for procedure codes used by a Medicaid dental provider to bill for ARKids First-B preventive dental services.

|222.750 Health Education |2-1-20 |

Health education is a required component of screening services and includes anticipatory guidance. The developmental assessment, comprehensive, physical examination, and the visual, hearing or dental screening provide the initial opportunity for providing health education. Health education and counseling to parents (or guardians) and children are required. Health education and counseling are designed to assist in understanding what to expect in terms of the child’s development and to provide information about the benefits of healthy lifestyles and practices, as well as accident and disease prevention. See Section 262.130 for procedure codes.

Health education can include but isn’t limited to tobacco cessation counseling services to the parent/legal guardian of the child.

A. Counseling Visits (two (2) per SFY):

|Current Procedure Code |Current Modifier |Arkansas Medicaid Description |

|99406* |SE |((Smoking and tobacco use cessation counseling visit; intermediate, 15-minutes) |

|99406* |CG |( (Smoking and tobacco use cessation counseling visit, intermediate, 15-minutes |

| | |provided to parents of children birth through twenty (20) years of age) |

|99407* |SE |((Smoking and tobacco use cessation counseling visit; intensive, 30-minutes) |

|99407* |CG |( (Smoking and tobacco use cessation counseling visit, intensive, 30-minutes provided |

| | |to parents of children birth through twenty (20) years of age) |

* Exempt from PCP referral requirements.

((…) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the service. When using a procedure code with this symbol, the service must meet the indicated Arkansas Medicaid description.

B. Referral of patient to an intensive tobacco cessation referral program.

C. These counseling sessions can be billed in addition to an office visit or EPSDT.

D. If the beneficiary is under the age of eighteen (18), and the parent/legal guardian smokes, he or she can be counseled as well, and the visit billed under the minor’s beneficiary Medicaid number. The provider cannot prescribe meds for the parent under the child’s Medicaid number. A parent/legal guardian session will count towards the four (4) counseling sessions limit described in section C above.

E. Tobacco cessation sessions do NOT require a PCP referral.

F. The provider must complete the counseling checklist and place in the patient records for audit. View or Print the Arkansas Be Well Referral Form.

Refer to Section 257.000 and Section 292.900 of the Primary Care Physician manual for more information.

|222.800 Schedule for Preventive Health Screens |1-1-20 |

The ARKids First – B periodic screening schedule follows the guidelines for the EPSDT screening schedule and is updated in accordance with the recommendations of the American Academy of Pediatrics.

From birth to 15 months of age, children may receive six (6) periodic screens in addition to the newborn screen performed in the hospital.

Children age 15 months to 24 months of age may receive two (2) periodic screens. Children age 24 months to 30 months may receive one (1) periodic screen, and children 30 months to 3 years old may receive one (1) periodic screen.

When a child has turned 3 years old, the following schedule will apply. There must be at least 365 days between each screen listed below for children age 3 years through 18 years.

|Age |

|3 years |7 years |11 years |15 years |

|4 years |8 years |12 years |16 years |

|5 years |9 years |13 years |17 years |

|6 years |10 years |14 years |18 years |

Medical screens for children are required to be performed by the beneficiary’s PCP or receive a PCP referral to an authorized Medicaid screening provider. Routine newborn care, vision screens, dental screens and immunizations for childhood diseases do not require PCP referral. See Section 262.130 for procedure codes.

|222.810 Newborn Screen (Ages 3 to 5 Days) |1-1-20 |

A. History (initial/interval) to be performed.

B. Measurements to be performed:

1. Height and Weight

2. Head Circumference

C. Physical Examination to be performed at 3 to 5 days of age. At each visit a completed physical examination is essential with the infant totally unclothed.

D. Developmental/Surveillance and Psychosocial/Behavioral Assessment, to be performed by history and appropriate physical examination and, if suspicious, by specific objective developmental testing. Parenting skills should be fostered at every visit

E. Procedures—General

These may be modified depending upon the entry point into the schedule and the individual need.

1. Hereditary/Metabolic Screening to be performed at age 1 month, if not performed either during the newborn evaluations or at the preferred one of 3-5 days. Metabolic screening (e.g., thyroid, hemoglobinopathies, PKU, galactosemia) should be done according to state law.

2. Immunization(s) to be performed as appropriate. Every visit should be an opportunity to update and complete a child’s immunizations.

|222.820 Infancy (Ages 1–9 Months) |1-1-20 |

A. History (Initial/Interval) to be performed at ages 1, 2, 4, 6, and 9 months.

B. Measurements to be performed

1. Height and Weight at ages 1, 2, 4, 6, and 9 months.

2. Head Circumference at ages 1, 2, 4, 6, and 9 months.

C. Sensory Screening, subjective, by history

1. Vision at ages 1, 2, 4, 6, and 9 months.

2. Hearing at ages 1, 2, 4, 6, and 9 months.

D. Developmental/Surveillance and Psychosocial/Behavioral Assessment to be performed at ages 1, 2, 4, 6, and 9 months; to be performed by history and appropriate physical examination and, if suspicious, by specific objective developmental testing. Parenting skills should be fostered at every visit.

E. Physical Examination to be performed at ages 1, 2, 4, 6, and 9 months. At each visit, a complete physical examination is essential with the infant totally unclothed.

F. Procedures - General

These may be modified depending upon the entry point into the schedule and the individual need.

1. Hereditary/Metabolic Screening to be performed at age 1 month, if not performed either during the newborn evaluation or at the preferred age of 3-5 days. Metabolic screening (e.g., thyroid, hemoglobinopathies, PKU, galactosemia) should be done according to state law.

2. Immunization(s) to be performed at ages 1, 2, 4, 6, and 9 months. Every visit should be an opportunity to update and complete a child’s immunizations.

3. Hematocrit or Hemoglobin risk assessment at 4 months with appropriate testing of high risk factors.

G. Other Procedures

1. Lead screening risk assessment to be performed at ages 6 and 9 months. Additionally, screening should be done in accordance with state law where applicable.

2. Tuberculin surveillance to be performed at ages 1 and 6 months per recommendations of the American Academy of Pediatrics (AAP) Committee on Infectious Diseases, published in the current edition of AAP Red Book: Report of the Committee on Infectious Diseases. Testing should be performed on recognition of high risk factors.

H. Anticipatory Guidance to be performed at ages 1, 2, 4, 6, and 9 months. Age-appropriate discussion and counseling should be an integral part of each visit for care.

1. Injury prevention at ages 1, 2, 4, 6, and 9 months.

2. Violence prevention at ages 1, 2, 4, 6, and 9 months.

3. Sleep positioning counseling at ages 1, 2, 4, and 6 months. Parents and caregivers should be advised to place healthy infants on their backs when putting them to sleep. Side positioning is a reasonable alternative but carries a slightly higher risk of SIDS.

4. Nutrition counseling at ages 1, 2, 4, 6, and 9 months. Age-appropriate nutrition counseling should be an integral part of each visit.

I. Oral Health risk assessment: The Bright Futures/AAP “Recommendation for Preventative Pediatric Health Care,” (i.e. Periodicity Schedule) recommends all children receive a risk assessment at the 6- and 9-month visits. For the 12-, 18-, 24-, 30-month, and the 3- and 6-year visits, risk assessment should continue if a dental home has not been established. View the Bright/AAP Periodicity Schedule

Subsequent examinations should be completed as prescribed by the child’s dentist and recommended by the Child Health Services (EPSDT) dental schedule.

J. Developmental Screen to be performed at age 9 months using a standardized tool such as the Ages and Stages Questionnaire (ASQ) or Brigance Screens II. Any additional test must be approved by the Division of Medical Services (DMS) prior to use.

|222.830 Early Childhood (Ages 12 Months–4 Years) |1-1-20 |

A. History (Initial/Interval) to be performed at ages 12, 15, 18, 24, and 30 months and ages 3 and 4 years.

B. Measurements to be performed

1. Height and Weight at ages 12, 15, 18, 24, and 30 months and ages 3 and 4 years.

2. Head Circumference at ages 12, 15, 18, and 24 months.

3. Blood Pressure at ages 30 months*, 3 and 4 years.

*Note: For infants and children with specific risk conditions.

4. BMI (Body Mass Index) at ages 24 and 30 months, 3 and 4 years.

C. Sensory Screening, subjective, by history

1. Vision at ages 12, 15, 18, 24, and 30 months

2. Hearing at ages 12, 15, 18, 24, and 30 months and age 3 years.

D. Sensory Screening, objective, by a standard testing method

1. Vision at ages 3 and 4 years. Note: If the 3-year-old patient is uncooperative, re-screen within 6 months.

2. Hearing at age 4 years.

E. Developmental/Surveillance and Psychosocial/Behavioral Assessment to be performed at ages 12, 15, 18, 24, and 30 months and ages 3 and 4 years. To be performed by history and appropriate physical examination and, if suspicious, by specific objective developmental testing. Parenting skills should be fostered at every visit.

F. Physical Examination to be performed at ages 12, 15, 18, 24, and 30 months and ages 3 and 4 years. At each visit, a complete physical examination is essential, with the infant totally unclothed or with the older child undressed and suitably draped.

G. Procedures – General

These may be modified depending upon the entry point into the schedule and the individual need.

1. Immunization(s) to be performed at ages 12, 15, 18, 24, and 30 months and ages 3 and 4 years. Every visit should be an opportunity to update and complete a child’s immunizations.

2. Hematocrit or Hemoglobin risk assessment at 4 months with appropriate testing and follow up action if high risk to be performed at ages 12, 15, 18, 24, and 30 months and ages 3 and 4 years.

H. Other Procedures

Testing should be done upon recognition of high risk factors.

1. Lead screening risk assessment to be performed at ages 12 and 24 months. Additionally, screening should be done in accordance with state law where applicable, with appropriate action to follow if high risk positive.

2. Tuberculin test to be performed at ages 12 and 24 months and ages 3 and 4 years. Testing should be done upon recognition of high-risk factors per recommendations of the Committee on Infectious Diseases, published in the current edition of AAP Red Book: Report of the Committee on Infectious Diseases. Testing should be performed on recognition of high risk factors.

3. Risk Assessment for Hyperlipidemia to be performed at ages 24 months and 4 years with fasting screen, if family history cannot be ascertained, and other risk factors are present, screening should be at the discretion of the physician.

I. Anticipatory Guidance to be performed at ages 12, 15, 18, 24, and 30 months and at ages 3 and 4 years. Age-appropriate discussion and counseling should be an integral part of each visit for care.

1. Injury prevention to be performed at ages 12, 15, 18, 24, and 30 months and at ages 3 and 4 years.

2. Violence prevention to be performed at ages 12, 15, 18, 24, and 30 months and at ages 3 and 4 years.

3. Nutrition counseling to be performed at ages 12, 15, 18, 24, and 30 months and ages 3 and 4 years. Age-appropriate nutrition counseling should be an integral part of each visit.

J. Oral Health Risk assessment: The Bright Futures/AAP “Recommendation for Preventative Pediatric Health Care,” (i.e, Periodicity Schedule) recommends all children receive a risk assessment at the 6- and 9-month visits. For the 12-, 18-, 24-, 30-month, and the 3- and 6-year visits, risk assessment should continue if a dental home has not been established. View the Bright/AAP Periodicity Schedule .

Subsequent examinations should be as prescribed by the dentist and recommended by the Child Health Services (EPSDT) dental schedule.

K. Developmental Screen to be performed at age 18 and 30 months using standardized tools such as the Ages and Stages Questionnaire (ASQ) or Brigance Screens-II. Any additional tests must be approved by DMS prior to use.

L. Autism Screen to be performed at age 18 and 24 months (or 30 months if screen was not completed at 24 months) using a standardized tool such as the Modified Checklist for Autism in Toddlers (M-CHAT) or the Pervasive Developmental Disorders Screening Tests-II (PDDSDT-II) Stage1. Any additional test must be approved by DMS prior to use.

|222.840 Middle Childhood (Ages 5 - 10 Years) |1-1-20 |

A. History (Initial/Interval) to be performed at ages 5, 6, 7, 8, 9, and 10 years.

B. Measurements to be performed

1. Height and Weight at ages 5, 6, 7, 8, 9, and 10 years.

2. Blood Pressure at ages 5, 6, 7, 8, 9, and 10 years.

3. Body Mass Index at ages 5, 6, 7, 8, 9, and 10 years.

C. Sensory Screening, objective, by a standard testing method

1. Vision at ages 5, 6, 8, and 10 years.

2. Hearing at ages 5, 6, 8, and 10 years.

D. Sensory Screening, subjective, by history.

1. Vision at ages 7 and 9.

2. Hearing at ages 7 and 9.

E. Developmental/Surveillance and Psychosocial/Behavioral Assessment to be performed at ages 5, 6, 7, 8, 9, and 10 years. To be performed by history and appropriate physical examinations and, if suspicious, by specific objective developmental testing. Parenting skills should be fostered at every visit.

F. Physical Examination to be performed at ages 5, 6, 7, 8, 9, and 10 years. At each visit, a complete physical examination is essential with the child undressed and suitably draped.

G. Procedures - General

These may be modified depending upon entry point into schedule and individual need.

1. Immunization(s) to be performed at ages 5, 6, 7, 8, 9, and 10 years. Every visit should be an opportunity to update and complete a child’s immunizations.

2. Hematocrit or Hemoglobin to be performed for patients at high risk at ages 5, 6, 7, 8, 9, and 10 years.

3. High Cholesterol to be performed at least once between the ages of 9 and 11, using a non-HDL cholesterol test that does not require fasting. Abnormal results should be followed up with a fasting lipid profile.

H. Other Procedures

Testing should be done upon recognition of high-risk

1. Tuberculin test to be performed at ages 5, 6, 7, 8, 9, and 10 years. Testing should be done upon recognition of high-risk factors.

2. Risk Assessment for Hyperlipidemia to be performed at ages 6, 7, 8, 9, and 10 years with fasting if family history cannot be ascertained, and other risk factors are present, screening should be at the discretion of the physician.

3. Oral Health Risk Assessment: The Bright Futures/AAP “Recommendation for Preventative Pediatric Health Care,” (i.e, Periodicity Schedule) recommends all children receive a risk assessment at the 6- and 9-month visits. For the 12-, 18-, 24-, 30-month, and the 3- and 6-year visits, risk assessment should continue if a dental home has not been established. View the Bright/AAP Periodicity Schedule .

Subsequent examination should be as prescribed by the dentist and recommended by the Child Health Services (EPSDT) dental schedule.

I. Anticipatory Guidance to be performed at ages 5, 6, 7, 8, 9, and 10 years. Age-appropriate discussion and counseling should be an integral part of each visit for care.

1. Injury prevention to be performed at ages 5, 6, 7, 8, 9, and 10 years.

2. Violence prevention to be performed at ages 5, 6, 7, 8, 9, and 10 years.

3. Nutrition counseling to be performed at ages 5, 6, 7, 8, 9, and 10 years. Age-appropriate counseling should be an integral part of each visit.

|222.850 Adolescence (Ages 11 - 18 Years) |1-1-20 |

Developmental, psychosocial and chronic disease issues for children and adolescents may require frequent counseling and treatment visits separate from preventive care visits.

A. History (Initial/Interval) to be performed at ages 11, 12, 13, 14, 15, 16, 17, and 18 years.

B. Measurements to be performed

1. Height and Weight at ages 11, 12, 13, 14, 15, 16, 17, and 18 years.

2. Blood Pressure at ages 11, 12, 13, 14, 15, 16, 17, and 18 years.

3. Body Mass Index at ages: 11, 12, 13, 14, 15, 16, 17, and 18 years.

C. Sensory Screening, subjective, by history

1. Vision at ages 11, 13, 14, 16, and 17 years.

2. Hearing at ages 11, 12, 13, 14, 16, 17, and 18 years.

D. Sensory Screening, objective, by a standard testing method

1. Vision at ages 12, 15, and 18 years.

2. Hearing at ages 12, 15, and 18 years.

E. Developmental/Surveillance and Psychosocial/Behavioral Assessment to be performed at ages 11, 12, 13, 14, 15, 16, 17, and 18 years. To be performed by history and appropriate physical examination, if suspicious, by specific objective developmental testing. Parenting skills should be fostered at every visit.

F. Physical Examination to be performed at ages 11, 12, 13, 14, 15, 16, 17, and 18 years. At each visit, a complete physical examination is essential, with the child undressed and suitably draped.

G. Procedures – General

These may be modified, depending upon entry point into schedule and individual need.

1. Immunization(s) to be performed at ages 11, 12, 13, 14, 15, 16, 17, and 18 years. Every visit should be an opportunity to update and complete a child’s immunizations.

2. High Cholesterol screening to be performed at least once between the ages of 17 and 18, using a non-HDL cholesterol test that does not require fasting. Abnormal results should be followed up with a fasting lipid profile.

H. Other Procedures

Testing should be done upon recognition of high risk factors.

1. Tuberculin test to be performed at ages 11, 12, 13, 14, 15, 16, 17, and 18 years.

2. Risk assessment for Hyperlipidemia to be performed annually with fasting screen if family history cannot be ascertained and other risk factors are present. Screening should be at the discretion of the physician.

3. Hematocrit or Hemoglobin to be performed for those patients at high risk at ages 11-18.

4. STI/HIV screening to be performed at ages 11, 12, 13, 14, 15, 16, 17, and 18 years. All sexually active patients should be screened for sexually transmitted diseases (STDs). Adolescents should be screened for sexually transmitted infections (STIs) per recommendations in the current addition of the AAP Red Book: Report of the Committee on Infectious Diseases, Additionally, all adolescents should be screened for HIV according to the AAP statement once between the ages of 16 and 18, making every effort to preserve confidentiality of the adolescent. Those at increased risk of HIV infection, including those who are sexually active, participate in injection drug use, or are being tested for other STIs, should be tested for HIV and reassessed annually

5. Depression screening ages 12 through 18 using screening tools such as Patient Health Questionnaire (PHQ)-2 or other tools available in the GLAD-PC toolkit.

I. Anticipatory Guidance to be performed at ages 11, 12, 13, 14, 15, 16, 17, and 18 years. Age-appropriate discussion and counseling should be an integral part of each visit for care.

1. Injury prevention to be performed at ages 11, 12, 13, 14, 15, 16, 17, and 18 years.

2. Violence prevention to be performed at ages 11, 12, 13, 14, 15, 16, 17, and 18 years.

3. Nutrition counseling to be performed at ages 11, 12, 13, 14, 15, 16, 17, and 18 years. Age-appropriate nutrition counseling should be an integral part of each visit.

|222.900 Substance Abuse Treatment Services |8-1-18 |

Substance abuse treatment services have been integrated into the Outpatient Behavioral Health Services system. Refer to Section II of the Outpatient Behavioral Health Services manual for service definitions, information regarding reimbursement, PCP referral, extension of benefit requirements and other information.

|223.000 Extended Benefits | |

|223.100 Medical Supplies Extended Benefits |4-1-09 |

Beneficiaries in the ARKids First-B Program are allowed a monthly benefit of $125.00 for medically necessary medical supplies (see Section 222.100). Covered medical supplies are listed in Section 262.110 of this manual. In unusual circumstances, when a beneficiary’s condition requires additional medical supplies that exceed the monthly benefit, the provider may request extended benefits. To apply for extended benefits for medically necessary medical supplies, Prosthetics and Home Health Providers must refer to and adhere to guidelines detailed in their respective provider manuals.

|223.200 Occupational, Physical and Speech Therapy Extended Benefits |8-1-15 |

If the referring PCP or attending physician, in conjunction with the treating occupational, physical or speech therapy provider, determines the beneficiary requires additional daily speech therapy services other than those allowed through regular benefits indicated in Section 222.600, a request for extended therapy services may be made. The therapist must refer to the guidelines in the Occupational, Physical and Speech Therapy Provider Manual to properly apply for extended benefits.

|224.000 Cost Sharing |10-1-15 |

Co-payment or coinsurance applies to all ARKids First-B services, with the exception of immunizations, preventive health screenings, family planning, prenatal care, eyeglasses, medical supplies and audiological services (only Tympanometry, CPT procedure code 92567, when the diagnosis is within the ICD range (View ICD codes.)). Co-payments or coinsurances range from up to $5.00 per prescription to 10% of the first day’s hospital Medicaid per diem.

ARKids First-B families have an annual cumulative cost sharing maximum of 5% of their annual gross family income. The annual period is July 1 through June 30 SFY (state fiscal year). The ARKids First-B beneficiary’s annual cumulative cost sharing maximum will be recalculated and the cumulative cost sharing counter reset to zero on July 1 each year.

The cost sharing provision will require providers to check and be alert to certain details about the ARKids First-B beneficiary’s cost sharing obligation for this process to work smoothly. The following is a list of guidelines for providers:

1. On the day service is delivered to the ARKids First-B beneficiary, the provider must access the eligibility verification system to determine if the ARKids First-B beneficiary has current ARKids First-B coverage and whether or not the ARKids First-B beneficiary has met the family’s cumulative cost sharing maximum.

2. The provider must check the remittance advice received with the claim submitted on the ARKids First-B beneficiary, which will contain an explanation stating that the ARKids First-B beneficiary has met their cost sharing cap.

3. It is strongly urged that providers submit their claims as quickly as possible to the Arkansas Medicaid fiscal agent for payment so that the amount of the ARKids First-B beneficiary’s co-payment can be posted to their cost share file and the amount added to the accrual.

|224.100 Co-payment |6-1-10 |

Refer to Section 221.100 of this manual for services that require a co-payment. Co-payments for ARKids First-B beneficiaries are up to $5.00 per prescription and $10.00 per visit for outpatient services and $10.00 per trip for Emergency Ambulance Services.

|224.200 Co-insurance |2-1-10 |

Refer to Section 221.100 of this manual for services that require co-insurance.

|224.210 Durable Medical Equipment Co-insurance |7-1-11 |

Durable Medical Equipment (DME) will require a co-insurance amount equal to 10% of the Medicaid allowed amount per item.

|224.220 Inpatient Hospital Co-Insurance |8-1-15 |

The co-insurance charge per inpatient hospital admission (including services in an inpatient psychiatric hospital and a psychiatric residential treatment facility) for ARKids First-B beneficiaries is10% of the hospital’s Medicaid per diem, applied on the first covered day. For example:

An ARKids First-B beneficiary is an inpatient for four (4) days in a hospital with an Arkansas Medicaid per diem of $500.00. When the hospital files a claim for four (4) days, ARKids First-B will pay $1950.00; the beneficiary will pay $50.00.

Four (4 days) times $500.00 (the hospital per diem) = $2000.00 (hospital allowed amount).

Ten percent (10% ARKids First-B co-insurance rate) of $500.00 = $50.00 co-insurance.

Two thousand dollars ($2000.00 hospital allowed amount) minus $50.00 (co-insurance) = $1950.00 (ARKids First-B payment).

The ARKids First-B beneficiary is responsible for paying a co-insurance amount equal to 10% of the per diem for one (1) day, which is $50.00 in the above example.

|240.000 PRIOR AUTHORIZATION | |

|240.050 Prior Authorization (PA) Procedures |2-1-10 |

Procedures requiring prior authorization (PA) in the Arkansas Medicaid Program also require PA for ARKids First-B beneficiaries. Refer to the appropriate Arkansas Medicaid Provider Manual for details.

Prior authorization is also required for interperiodic preventive dental screens. Refer to Section 240.200 for details.

|240.100 Inpatient Hospital Medicaid Utilization Management Program (MUMP) |10-13-03 |

Pre-certification of inpatient hospital stays applies to ARKids First-B-covered admissions in exactly the same manner as it applies to Medicaid-covered admissions. Refer to the Physician/Independent Lab/CRNA/Radiation Therapy Center Provider Manual and the Hospital/Critical Access Hospital/End-Stage Renal Disease Provider Manual for the pre-certification procedures.

|240.200 Prior Authorization (PA) Process for Interperiodic Preventive Dental Screens |4-1-09 |

Prior authorization for procedure code D0140, Interperiodic Dental Screening Exam, must be requested on the ADA claim form or online with a brief narrative through the Prior Authorization Manipulation (PAM) software. View or print the Department of Human Services Medicaid Dental Unit Address. Refer to your Arkansas Medicaid Dental Services Provider Manual for detailed information on obtaining prior authorizations.

Refer to Section 222.300 of this manual for coverage and Section 262.150 billing information.

|240.300 Prior Authorization (PA) for Outpatient and Inpatient Mental Health Services |10-14-16 |

Certain outpatient and inpatient mental health services require prior authorization. See the appropriate provider manual for a list of procedure codes that require PA. Requests for PA must be sent to the PA contractor. View or print current contractor contact information.

|240.400 Prior Authorization for Other Services |7-1-04 |

Prior authorization may be required for services that are not specifically mentioned in this manual. Refer to the appropriate Medicaid Provider Policy Manual for information.

|241.000 Beneficiary or Provider Appeal Process |4-1-09 |

When an adverse extended services or prior authorization request decision is made, the provider may request an administrative reconsideration and/or the provider and/or the beneficiary may file for a fair hearing or appeal of the denial of services decision as provided is Section 190.003 of this manual. The appeal request must be in writing and received by the Appeals and Hearings Section of the Department of Human Services within thirty days of the date on the letter explaining the denial. Appeal requests must be submitted to the Department of Human Services Appeals and Hearings Section. Further details, guidelines and procedures are outlined and provided within the respective discipline’s Medicaid Provider Manual. Refer to your individual specialty provider manual for further assistance. View or print the Department of Human Services Appeals and Hearings Section address.

|250.000 REIMBURSEMENT | |

|250.010 Reimbursement Introduction |2-1-10 |

Reimbursement for services provided to ARKids First-B beneficiaries is based on the current Medicaid reimbursement methodology of the corresponding Medicaid program or service.

ARKids First-B family’s annual cost-sharing has a 5% maximum.

When Providers Are Required To Refund a Co-pay or Co-insurance:

Providers will be required to refund to ARKids First-B families the amount that the provider collected from the family for cost-sharing if, at the time the claim is submitted and processed, the system determines that the family’s cumulative cost-sharing maximum has been met. This may happen even though the family was required to provide cost-sharing on the date of service when the provider waits a period of time to submit the claim to Medicaid.

Example: The family has not met its cost-sharing maximum on the date of service. Therefore, the provider collects the required cost-share amount. The provider submits the claim two months later. In the interim, the family’s annual cumulative cost-sharing maximum has been met and the family will not be required to cost-share again until the next SFY. The system cannot track cost-sharing until the claim is processed. In this case, even though the family was required to cost-share on the date of service, that amount is not in the system until the claim is processed. On the date the claim adjudicated, the family had met its obligation for cost-sharing (i.e. other claims were adjudicated). Therefore, the provider must refund to the family the amount that the family paid. There will be a statement on the remittance advice that the cost-sharing maximum has been met and that Medicaid is paying the full Medicaid allowed rate for the service.

|250.020 Fee Schedules |12-1-12 |

Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at 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.

|260.000 BILLING Procedures | |

|261.000 Introduction to Billing |2-1-10 |

Billing procedures for services provided to ARKids First-B beneficiaries are the same as those for Medicaid covered services. Refer to Section II of the appropriate Arkansas Medicaid Provider Manual for billing procedures.

|261.100 Timely Filing |10-13-03 |

The timely filing requirements outlined in Section III of your Arkansas Medicaid Provider Manual apply to the ARKids First-B Program.

|262.000 ARKids First-B Billing Procedures | |

|262.100 CPT and/or HCPCS Procedure Codes |12-15-12 |

National codes must be used for both electronic and paper claims. Where only a local code is available, it can be used indefinitely, but it can be billed only on a paper claim.

((…) 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.

|262.110 Medical Supplies Procedure Codes |3-15-13 |

The following medical supplies procedure codes may be billed by Medicaid-enrolled Home Health and Prosthetics providers for ARKids First-B beneficiaries.

|Procedure Code |Required Modifier(s) |Description |

|A4206 |NU |Syringe with needle, sterile < or = to1cc |

|A4207 |NU |Syringe with needle, sterile 2 cc, each |

|A4209 |NU |Syringe with needle, sterile 5 cc or greater, each |

|A4216 |NU |Sterile water/saline, 10 ml |

|A4217 |NU |Sterile water/saline, 500 ml |

|A4221* |NU |Supplies for maintenance of drug infusion catheter per week |

|A4222* |NU |Supplies for external drug infusion pump per cassette or bag |

|A4253 |NU |Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips |

| | |Billed for Pregnant Women services only |

|A4253 |NU, U1 | |

|A4256 |NU |Normal, low and high calibrator solution/chips |

|A4259 |NU |Lancets, per box |

|A4259 |NU, U2 |Billed for Pregnant Women services only |

|A4265 |NU |Paraffin |

|A4310 |NU |Insertion tray without drainage bag and without catheter |

|A4311 |NU |Insertion tray without drainage bag with indwelling catheter |

|A4312 |NU |Insertion tray without drainage bag with indwelling catheter |

|A4313 |NU |Insertion tray without drainage bag with indwelling catheter |

|A4314 |NU |Insertion tray with drainage bag with indwelling catheter |

|A4315 |NU |Insertion tray with drainage bag with indwelling catheter |

|A4316 |NU |Insertion tray with drainage bag with indwelling catheter |

|A4320 |NU |Irrigation tray with bulb or piston syringe, any purpose |

|A4322 |NU |Irrigation syringe, bulb or piston |

|A4326 |NU |Male external catheter specialty type, e.g.; inflatable, |

|A4327 |NU |Female external urinary collection device; metal cup, each |

|A4328 |NU |Female external urinary collection device; pouch, each |

|A4330 |NU |Perianal fecal collection pouch with adhesive |

|A4331 |NU |External drainage tube, any type/length, for urine leg bag/urostomy pouch, ea |

|A4338 |NU |Indwelling catheter; foley type, two-way latex with coating |

|A4340 |NU |Indwelling catheter; specialty type, e.g.; Coude, mushroom |

|A4344 |NU |Indwelling catheter; foley type, two-way, all silicone |

|A4346 |NU |Indwelling catheter; foley type, three way for continuous |

|A4349 |NU |Male external catheter w/integral collection compartment |

|A4351 |NU |Intermittent urinary catheter, disposable straight tip |

|A4351 |NU, U1 | |

|A4352 |NU |Intermittent urinary catheter disposable Coude (curved) |

|A4352 |NU,U1 | |

|A4353 |NU |Urinary intermittent catheter with insertion supplies |

|A4353 |NU,U2 | |

|A4354 |NU |Insertion tray with drainage bag but without catheter |

|A4355 |NU |Irrigation tubing set for continuous bladder irrigation |

|A4356 |NU |External urethral clamp or compression device (not to be used for catheter clamp), |

| | |each |

|A4357 |NU |Bedside drainage bag, day or night, with or without anti reflux |

|A4358 |NU |Urinary leg bag; vinyl, with or without tube |

|A4361 |NU |Ostomy faceplate |

|A4362 |NU |Skin barrier; solid, 4 x 4 or equivalent, each |

|A4364 |NU |Adhesive for ostomy or catheter; liquid (spray, brush, etc.) |

|A4367 |NU |Ostomy belt |

|A4368 |NU |Ostomy filters, any type, each |

|A4369 |NU |Ostomy skin barrier liquid spray, brush, etc. |

|A4371 |NU |Ostomy skin barrier powder, per oz |

|A4394 |NU |Ostomy deodorant, all types, per ounce |

|A4397 |NU |Irrigation supply; sleeve |

|A4398 |NU |Irrigation supply; bags |

|A4399 |NU |Irrigation supply; cone/catheter |

|A4400 |NU |Ostomy irrigation set |

|A4402 |NU |Lubricant |

|A4404 |NU |Ostomy rings |

|A4405 |NU |Ostomy skin barrier, non-pectin based paste, per oz. |

|A4406 |NU |Ostomy skin barrier, non-pectin based paste, per oz. |

|A4407 |NU |Ostomy skin barrier w/flange, ext wear, w/built in convexity 4x4 or 48 sq in |

|A6228 |NU |Gauze, impregnated, water or NS pad size 16 sq in or less |

|A6229 |NU |Gauze, impregnated, water or NS, pad size > 16 in but < 48 sq in |

|A6230 |NU |Gauze, impregnated, water or NS, pad size > 48 sq in |

|A6234 |NU |Hydrocolloid dressing, each (16 square inches or less) |

|A6235 |NU |Hydrocolloid dressing, each (more than 16, but less than 48 square inches) |

|A6237 |NU |Hydrocolloid dressing, wound cover, pad size 16 sq in or less with adhesive |

|A6238 |NU, U1 |Hydrocolloid dressing, each (more than 48 square inches) |

|A6241 |NU |Hydrocolloid dressing, wound cover, pad size 16 sq in or less w/o adhesive |

|A6242 |NU |Hydrogel dressing, each (16 square inches or less) |

|A6243 |NU |Hydrogel dressing, each (more than 16, but less than 48 square inches) |

|A6244 |NU |Hydrogel dressing, each (more than 48 square inches) |

|A6245 |NU |Hydrogel dressing, each (16 square inches or less) |

|A6246 |NU |Hydrogel dressing, each (more than 16, but less than 48 square inches) |

|A6247 |NU |Hydrogel dressing, each (more than 48 square inches) |

|A6248 |NU |Hydrogel dressing, each (1 ounce), wound filler, gel |

|A6257 |NU |Transparent film, each (16 square inches or less) |

|A6258 |NU |Transparent film, each (more than 16, but less than 48 square inches) |

|A6259 |NU |Transparent film, each (more than 48 square inches) |

|A6403 |NU |Gauze, non-impregnated, sterile, pad size more than 16 sq in but = to or 48 sq in |

|A6441 |NU |Padding Bandage, non-elastic, width > or = I in & < 5 in per yd |

|A6442 |NU |Conform bandage, non-elastic, non-sterile, width < 3 in, per yd |

|A6443 |NU |Conform bandage, non-elastic, non-sterile, width > or = 3 in & < 5 in, per y |

|A6444 |NU |Conform bandage, non-elastic, non-sterile, width > or = 5 in, per yd |

|A6445 |NU |Conform bandage, non-elastic, sterile, width < 3 in, per yd |

|A6446 |NU |Conform bandage, non-elastic, sterile, width > or = 3 in and < 5 in, per yd |

|A6447 |NU |Conform bandage, non-elastic, sterile, width > or = 5 in, per yd |

|A6448 |NU |Light compression bandage, elastic, width < 3 in, per yd |

|A6449 |NU |Gauze elastic, all types, per roll (linear yard) |

|A6450 |NU |Light compression bandage, elastic width > or = 5 in, per yd |

|A6451 |NU |Mod compress bandage, elastic, width > or = 3 in & < 5 in, per yd |

|A6452 |NU |High compress bandage, elastic, with > or = 3 in & < 5 in per yd |

|A6453 |NU |Self-adherent bandage, elastic, width < 3 in, per yd |

|A6454 |NU |Self-adherent bandage, elastic, width > or = 3 in & < 5 in, per yd |

|A6455 |NU |Self-adherent bandage, elastic, width > or = 5 in, per yd |

|A6549* ** |NU |Stocking, gradient compression; not otherwise specified |

|A7520 |NU |Trach/Laryngectomy tube, non-cuffed, PVC, silicone or equal, each |

|A7521 |NU |Trach/Laryngectomy tube, cuffed, PVC, silicone or equal, ea |

|A7522 |NU |Trach/Laryngectomy tube, stainless steel or equal, reusable, ea |

|B4100** |NU |Food thickener, administered orally, per oz. |

|E0601* |NU, RR |((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. |

|E0776 |NU |IV pole |

NOTE: *A4221, A4222, A6549 and E0601 must be prior authorized. Form DMS-679 must be used for the request for prior authorization. View or print form DMS-679 and instructions for completion.

**The costs of B4100 and A6549 are not subject to the $125 medical supplies monthly benefit limit.

((…) 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.

|262.120 Durable Medical Equipment (DME) Procedure Codes |11-1-17 |

The following DME HCPCS procedure codes may be billed with appropriate modifiers by Medicaid-enrolled prosthetics providers for ARKids First-B beneficiaries.

|HCPCS Code |Modifiers |Description |Payment Method |

|A4213 |NU |Syringes, sterile, 20 cc or greater, each |Purchase only |

|A4230 |NU |Infusion set for external insulin pump, non-needle cannula |Purchase only |

| | |type | |

|A4231* |NU |Infusion set for external insulin pump, needle (ea) |Purchase only |

|A4232* |NU |Syringe with needle for external insulin pump sterile (ea) |Purchase only |

|A4435 | |Ostomy pouch, drainable, high output, with extended wear |Purchase only |

| | |barrier (one-piece system), with or without (w/wo) filter, | |

| | |each | |

|A4627 |NU, UB |Spacer bag or reservoir, w/wo mask, for use with metered dose |Purchase only |

| | |inhaler | |

|A4627 |NU |Spacer bag or reservoir, with mask, for use with metered |Purchase only |

| | |inhaler | |

|A4635 |NU |Underarm pad, crutch, replacement, each |Purchase only |

| |UE | | |

|A4636 |NU |Replacement, handgrip, cane, crutch or walker, each |Purchase only |

| |UE | | |

|A4637 |NU |Replacement, tip, cane, crutch or walker, each |Purchase only |

| |UE | | |

|A4670 |NU |Electronic blood pressure monitor and cuff |Rental only |

|A6021 |NU |Polyskin/Collagen dressing 16 sq in or less |Purchase only |

|A6022 |NU |Polyskin/Collagen dressing >16 sq in but | |

|A6024 |NU |Polyskin/Collagen dressing wound filler per 6 in | |

|A7045 |NU |Exhalation port w/wo swivel used w/accessories for positive |Purchase only |

| | |airway device, replacement only | |

|A7046 |NU |Water chamber for humidifier, replacement, each |Purchase only |

|A7524 |NU |Tracheostoma stent/stud/button, each |Purchase only |

|A7525 |NU |Tracheostomy mask, each |Purchase only |

|E0100 |NU |Cane includes canes of all materials, adjustable |Purchase only |

|E0105 |NU |Cane, quad or three prong, includes canes of all materials, |Purchase only |

| |UE |adjustable or fixed, with tips | |

|E0110 |NU |Crutches, forearm, includes crutches of various materials, |Purchase only |

| |UE |complete, pair | |

|E0111 |NU |Crutch, forearm, includes crutches of various materials, |Purchase only |

| |UE |complete, each | |

|E0112 |NU |Crutches, underarm, wood, adjustable or fixed, pair |Purchase only |

| |UE | | |

|E0113 |NU |Crutches, underarm, wood, adjustable or fixed, each |Purchase only |

| |UE | | |

|E0114 |NU |Crutches underarm, aluminum, adjustable or fixed, pair |Purchase only |

| |UE | | |

|E0116 |NU |Crutch, underarm, aluminum, adjustable or fixed, each |Purchase only |

| |UE | | |

|E0130 |NU |Walker, rigid adjust, or fixed height |Purchase only |

| |UE | | |

|E0135 |NU |Walker, folding (pickup), adjustable or fixed height |Purchase only |

| |UE | | |

|E0141 |NU |Walker, wheeled, without seat |Purchase only |

| |UE | | |

|E0143 |NU |Folding walker, wheeled without seat |Purchase only |

| |UE | | |

|E0147 |NU |Heavy duty, multiple breaking system, variable |Purchase only |

| |UE | | |

|E0153 |NU |Platform attachment, forearm crutch, each |Purchase only |

| |UE | | |

|E0154 |NU |Platform attachment, walker each |Purchase only |

| |UE | | |

|E0155 |NU |Wheel attachment, rigid pickup walker, per pair |Purchase only |

| |UE | | |

|E0156 |NU |Seat attachment, walker |Purchase only |

|E0157 |NU |Crutch attachment, walker |Purchase only |

| |UE | | |

|E0158 |NU |Leg extensions for a walker |Purchase only |

| |UE | | |

|E0159 |NU |Brake attachment for wheeled walker, replacement, each |Purchase only |

|E0161 |NU |Sitz type bath, portable, fits over commode seat |Purchase only |

| |UE | | |

|E0163 |NU |Commode chair, stationary with fixed arms |Purchase only |

| |UE | | |

|E0167 |NU |Pail or pan for use with commode chair |Purchase only |

| |UE | | |

|E0175 |NU |Footrest, for use with commode chair, each |Purchase only |

| |UE | | |

|E0181^ |NU |Pressure pad, alternating with pump |Capped rental |

| |UE | | |

|E0182 |NU |Pump for alternating pressure pad |Purchase only |

| |UE | | |

|E0184 |NU |Floatation mattress, dry |Purchase only |

| |UE | | |

|E0185 |NU |Decubitus care pad, floatation or gel pad with foam leveling |Purchase only |

| |UE | | |

|E0186* |NU |Air pressure mattress |Purchase only |

|E0187* |NU |Water pressure mattress |Purchase only |

|E0189 |NU |Lambswool sheepskin pad, any size |Purchase only |

| |UE | | |

|E0190 |NU |Decubitus care mattress |Purchase only |

| |UE | | |

|E0191 |NU |Heel or elbow protector, each |Purchase only |

| |UE | | |

|E0196 |NU |Gel pressure mattress |Purchase only |

|E0197 |NU |Air pressure pad for mattress, standard mattress length and |Purchase only |

| |UE |width | |

|E0198* |NU |Water pressure pad for mattress, standard mattress length and |Purchase only |

| | |width | |

|E0200^ |NU |Heat lamp, without stand (table model) |Capped rental |

| |UE | | |

|E0202 |NU |Phototherapy (bilirubin) light with photometer |Rental only |

| |UE | | |

|E0205^ |NU |Heat lamp, with stand, includes bulb or infrared |Capped rental |

| |UE | | |

|E0217^ |NU |Water circulating heat pad with pump |Capped rental |

| |UE | | |

|E0225^ |NU |Hydrocollator unit, includes pads |Capped rental |

| |UE | | |

|E0235 |NU |Paraffin bath unit, portable |Purchase only |

| |UE | | |

|E0236^ |NU |Pump for water circulating pad |Capped rental |

| |UE | | |

|E0239^ |NU |Hydrocollator unit, portable |Capped rental |

| |UE | | |

|E0244 |NU |Raised toilet seat (manufacturer’s invoice must be attached to|Purchase only |

| | |paper claim) |Manually priced |

|E0249 |NU |Pad for water circulating heat unit |Purchase only |

| |UE | | |

|E0250^ |NU |Hospital bed, with side rails fixed height, with mattress |Capped rental |

|E0255^ |NU |Hospital bed, with side rails, variable heights, hi-lo, with |Capped rental |

| |UE |mattress | |

|E0260^ |RR |Hospital bed, semi-electric (head and foot adjustment) with |Capped rental |

| |KH |any type side rails, with mattress | |

| |UE | | |

|E0271^ |NU |Mattress, innerspring |Capped rental |

| |UE | | |

|E0272^ |NU |Mattress, foam rubber |Capped rental |

| |UE | | |

|E0273 |NU |Bed board |Purchase only |

| |UE | | |

|E0275 |NU |Bedpan, standard, metal or plastic |Purchase only |

| |UE | | |

|E0276 |NU |Bedpan, fracture, metal or plastic |Purchase only |

| |UE | | |

|E0280 |NU |Bed cradle, any type |Purchase only |

| |UE | | |

|E0325 |NU |Urinal; male, jug-type, any material |Purchase only |

| |UE | | |

|E0326 |NU |Urinal; female jug type, any material |Purchase only |

| |UE | | |

|E0424^ |NU |Stationary compressed gas system rental, includes contents |Rental only |

|E0430^ |NU |Portable gaseous oxygen system, includes contents |Rental only |

|E0435^ |NU |Oxygen system, liquid, portable, includes portable container |Rental only |

|E0439^ |NU |Stationary liquid oxygen system rental, includes contents |Rental only |

|E0443 |NU |Portable oxygen contents gaseous one month's supply |Purchase only |

|E0444 |NU |Portable oxygen contents liquid one month's supply |Purchase only |

|E0445^ |NU |Pulse oximeter (including 4 disposable probes) |Rental only |

|E0480^ |NU |Percussor, electric or pneumatic, home model |Capped rental |

| |UE | | |

|E0483 |UB |Replacement Pulmonary vest – vest only The manufacturer’s |Purchase only |

| | |invoice must be attached to the claim form. | |

|E0483 |RR |High-frequency chest-wall oscillation air-pulse generator |Rental only |

| | |system, includes hoses and vest | |

|E0560 |NU |Cascade humidification |Purchase only |

| |UE | | |

|E0565^ |NU |Compressor, air power source for equipment which is not |Capped rental |

| |UE |self-contained or cylinder-driven | |

|E0570 |NU |Nebulizer with compressor |Purchase only |

| |UE | | |

|E0575 |NU |Ultrasonic nebulizer |Capped rental |

| |UE | | |

|E0585^ |NU |Nebulizer, with compressor and heater |Capped rental |

| |UE | | |

|E0600 |NU |Suction pump |Rental only |

| |UE | | |

|E0605 |NU |Vaporizer room type |Purchase only |

| |UE | | |

|E0606^ |NU |Postural drainage board |Capped rental |

| |UE | | |

|E0607 |NU |Home blood glucose monitor |Purchase only |

| |UE | | |

| |NU, U1 |Billed for Pregnant Women services only | |

|E0630^ |NU |Patient lift, hydraulic, with seat or sling |Capped rental |

| |UE | | |

|E0650^ |NU |Pneumatic compressor, non-segmental |Capped rental |

| |UE | | |

|E0667^ |NU |Pneumatic appliance (leg) |Capped rental |

|E0668^ |NU |Pneumatic appliance (arm) |Capped rental |

|E0670 |EP |Segmental pneumatic appliance for use with pneumatic |Purchase only |

| | |compressor, integrated, 2 full legs and trunk | |

|E0691^ |NU |Ultraviolet light therapy system panel, bulbs/lamps/timer/eye |Rental only |

| | |protect < 2 sq. ft. treat area | |

|E0692^ |NU |Ultraviolet light therapy panel, bulbs/lamps/timer/eye |Rental only |

| | |protection, 4 ft. panel | |

|E0693^ |NU |Ultraviolet light therapy system panel, bulbs/lamps/timer/eye |Rental only |

| | |protection, 6 ft. panel | |

|E0694^ |NU |Ultraviolet light therapy system panel, bulbs/lamps/timer/eye |Rental only |

| | |protection, 6 ft. cabinet | |

|E0720^ |NU |TENS, two leads, localized stimulation |Capped rental |

| |UE | | |

|E0730^ |NU |TENS, four leads, larger area/multiple nerve stimulation |Capped rental |

| |UE | | |

|E0740 |NU |Replacement batteries for medically necessary TENS |Purchase only |

| |UE | | |

|E0745^ |NU |Neuromuscular stimulator, electronic shock unit |Capped rental |

| |UE | | |

|E0747^ |NU |Osteogenesis stimulator |Rental only |

| |UE | | |

|E0760* |NU |Osteogenesis stimulator, low intensity ultrasound, |Rental only |

| | |non-invasive | |

|E0779 |RR |Ambulatory infusion device, payable only when services are |Rental only |

|E0779^ | |provided to patients receiving chemotherapy, pain management | |

| | |or antibiotic treatment in the home | |

|E0840 |NU |Traction frame attached to headboard, simple cervical traction|Purchase only |

| |UE | | |

|E0850 |NU |Traction stand, free standing cervical traction |Purchase only |

| |UE | | |

|E0860 |NU |Traction equipment, over door, cervical |Purchase only |

|E0870 |NU |Traction frame attached to footboard, extremity traction |Purchase only |

| |UE | | |

|E0880 |NU |Traction stand, free standing, extremity, traction |Purchase only |

| |UE | | |

|E0890 |NU |Traction frame, attached to footboard, pelvic traction |Purchase only |

| |UE | | |

|E0900 |NU |Traction stand, free standing, pelvic traction |Purchase only |

| |UE | | |

|E0910^ |NU |Trapeze bars, attached to bed, complete with grab bar |Capped rental |

| |UE | | |

|E0920* ^ |NU |Fracture frame attached to bed, includes weights |Capped rental |

| |UE | | |

|E0930^ |NU |Fracture frame, free standing, includes weights |Capped rental |

| |UE | | |

|E0935^ |NU |Passive motion exercise device |Capped rental |

| |UE | | |

|E0936 |NU |Continuous passive motion exercise device for use other than |Capped Rental |

|Bill on paper | |knee | |

|E0940^ |NU |Trapeze bar, free standing, complete with grab bar |Capped rental |

| |UE | | |

|E0941^ |NU |Gravity assisted traction device, any type |Capped rental |

| |UE | | |

|E0942 |NU |Cervical head harness/halter |Purchase only |

| |UE | | |

|E0944 |NU |Pelvic belt/harness/boot |Purchase only |

| |UE | | |

|E0945 |NU |Extremity belt/harness |Purchase only |

| |UE | | |

|E0946 |NU |Fracture frame, dual with cross bars, attached |Purchase only |

| |UE | | |

|E0947 |NU |Fracture frame, attachments for complex pelvic |Purchase only |

| |UE | | |

|E0948 |NU |Fracture frame, attachments for complex cervical |Purchase only |

| |UE | | |

|E1130^ |NU |Standard wheelchair, fixed full length arms, fixed or swing |Capped rental |

| |UE |away detachable footrests | |

|E1140 |NU |With chair detachable arms, desk or full length |Capped rental |

|E1150 |NU |With chair detachable arms, desk or full length |Capped rental |

|E1160 |NU |With chair, fixed full length arms, swing away |Capped rental |

|E1224** ^ |NU |Footrest wheelchair with detachable arm |Capped rental |

| |UE | | |

|E1390^ |NU |Oxygen concentrator manufacturer specified maximum flow rate |Rental only |

|E1391* ^ |NU |O2 concentrator, dual delivery port, 85% or > O2 |Rental only |

| | |concentration, each | |

|E2601 |NU |General use wheelchair seat cushion, width less than 22 in., |Purchase only |

| | |any depth | |

|E2602 |NU |General use wheelchair seat cushion, width 22 in. or greater, |Purchase only |

| | |any depth | |

|E2611 |NU |General use wheelchair seat cushion, width 22 in. or greater, |Purchase only |

| | |any depth | |

|E2612 |NU |General use wheelchair seat cushion, width 22 in. or greater, |Purchase only |

| | |any depth | |

|E2622 |NU |Skin protection wheelchair seat cushion, adjustable, width |Purchase only |

| | |less than 22 in., any depth | |

|E2623 |NU |Skin protection wheelchair seat cushion, adjustable, width 22 |Purchase only |

| | |in. or greater, any depth | |

|E2624 |NU |Skin protection and positioning wheelchair seat cushion, |Purchase only |

| | |adjustable, width less than 22 in., any depth | |

|E2625 |NU |Skin protection and positioning wheelchair seat cushion, |Purchase only |

| | |adjustable, width 22 in. or greater, any depth | |

|K0739 |NU, UI |Durable medical equipment repair labor only (a maximum of 20 |Labor charges only |

| | |units per date of service is allowed) (1 unit = 15 minutes of | |

| | |labor) | |

|K0739 |NU |Durable medical equipment parts only. Repairs/parts will not |Manually priced |

| | |be approved for more than the allowed purchase price of new | |

| | |equipment. The manufacturer’s invoice for all parts must be | |

| | |attached to claim form. | |

|K0739 |NU, U4 |Maintenance for capped rental items |Labor charges only |

|L8605 | |Injectable bulking agent, dextranomer/hyaluronic acid |Purchase only |

| | |copolymer implant, anal canal, 1 ml, includes shipping and | |

| | |necessary supplies | |

NOTES: Codes denoted with an asterisk * (A4231, A4232, E0186, E0187, E0198, E0760, E0920, and E1391) must be prior authorized. Form DMS-679A must be used for the request for prior authorization. View or print form DMS-679A and instructions for completion.

** Code E1224 must be prior authorized through the Division of Medical Services, Utilization Review. Form DMS-679 must be used for the request for prior authorization. View or print form DMS-679 and instructions for completion.

Codes denoted with ^ symbol are approved for special circumstance “Initial” billing (See Section 242.111 of the Prosthetics Medicaid Provider Manual for details regarding “initial” billing). These codes must be billed WITHOUT A MODIFIER to indicate the “Initial” bill circumstance applies – EXCEPTION – if a modifier KH is specifically indicated, that modifier must be used.

|262.130 Preventive Health Screening Procedure Codes |10-1-15 |

There are two (2) types of full medical preventive health screening procedure codes to be used when billing for this service for ARKids First-B beneficiaries; Newborn and Child Preventive Health Screening:

1. ARKids First-B Preventive Health Screening: Newborn

The initial ARKids First-B preventive health screen for newborns is similar to Routine Newborn Care in the Arkansas Medicaid Physician and Child Health Services (EPSDT) Programs.

For routine newborn care following a vaginal delivery or C-section, procedure code 99460, 99461 or 99463, with the required modifier UA and a primary detail diagnosis (View ICD codes.) must be used one time to cover all newborn care visits by the attending provider. Payment of these codes is considered a global rate and subsequent visits may not be billed in addition to code 99460, 99461 or 99463. These codes include the physical exam of the baby and the conference(s) with the newborn’s parent(s), and are considered to be the Initial Health Screening.

For newborn illness care, e.g., neonatal jaundice, following a vaginal delivery or C-section, use procedure codes range 99221 through 99223. Do not bill codes 99460, 99461 or 99463 (routine newborn care) in addition to the newborn illness care codes.

2. ARKids First-B Preventive Health Screening: Children

Preventive health screenings in the ARKids First-B Program are similar to EPSDT screens in the Arkansas Medicaid Child Health Services (EPSDT) Program in content and application. Billing, however, differs from Child Health Services (EPSDT). All services, including the preventive health medical screenings, are billed in the CMS-1500 claim format for both electronic and paper claims.

All preventive health screenings after the newborn screen are to be billed using the preventive health screening procedure codes 99381-99385 or 99391-99395.

Providers may bill ARKids First-B for a sick child visit in addition to a preventive health screen procedure code (99381-99385 or 99391-99395) for the same date of service if the screening schedule indicates a periodic screen is due to be performed.

|Procedure Code |Required Modifier |Description |

|994601 |UA |Initial hospital/birthing center care, normal newborn (global). |

|994611 |UA |Initial care normal newborn other than hospital/birthing center (global). |

|994631 |UA |Initial hospital/birthing center care, normal newborn admitted/discharged same date of |

| | |service (global). |

|992211 | |Initial Newborn Care For Illness Care (e.g. neonatal jaundice) |

|992231 | | |

|99381-99385 | |Comprehensive Preventive Medicine Health Evaluation/Screen (New Patient) |

|99391-99395 | |Comprehensive Preventive Medicine Health Evaluation/Screen (Established Patient) |

|364152 | |Collection of venous blood by venipuncture |

|83655 | |Lead |

1 Exempt from PCP referral requirements

2 Covered when specimen is referred to an independent lab

3 Arkansas Medicaid description of the service

Immunizations and laboratory tests procedure codes are to be billed separately from comprehensive preventative health screens.

Billing for ARKids First-B services, including preventive health medical screenings and ARKids First-B SCHIP vaccine injection administration fees, are to be billed in the CMS-1500 claim format ONLY; for both electronic and paper claims.

|262.140 Speech-Language Pathology, Occupational, and Physical Therapy Procedure Codes | |

|262.141 Occupational, Physical, and Speech-Language Pathology Therapy Procedure Codes |1-1-21 |

Occupational, physical, and speech-language therapy procedure codes can be found in the following link: View or print the procedure codes for therapy services.

|262.150 Billing Procedure Codes for Periodic Dental Screens and Services and Orthodontia Services |8-1-15 |

A. Initial/Periodic Preventive Dental Screens

Periodicity schedule once each six months plus one day – must be billed with procedure code D0120.

B. Interperiodic Preventive Dental Screens

ARKids First-B beneficiaries may receive interperiodic preventive dental screening, if required by medical necessity. There are no limits on these services; however, prior authorization must be obtained in order to receive reimbursement. Refer to Section 240.200 of this manual for dental prior authorization information.

Procedure code D0140 must be billed for an interperiodic preventive dental screen. This service requires prior authorization (see Section 240.200).

The procedure codes listed in the table below must be billed for prophylaxis/fluoride.

|Procedure Code |Description |

|D1110 |Prophylaxis – adult (ages 10-18) |

|D1120 |Prophylaxis – child (ages 0-9) |

|D1208 |Topical application of fluoride (including prophylaxis) - all ages |

|D1206 |Topical application of fluoride varnish (ages 0-20) |

Refer to Section 222.300 for further details regarding dental services for ARKids First–B beneficiaries.

C. Orthodontia Services

|Comprehensive Orthodontic Treatment – Permanent Dentition |

|Procedure Code |Description |

|D8070 |Class I Malocclusion |

|D8080 |Class II Malocclusion |

|D8090 |Class III Malocclusion |

|Other Orthodontic Devices |

|Procedure Code |Description |

|D8210 |Removable appliance therapy |

|D8220 |Fixed appliance therapy |

|D8999 |Unspecified orthodontic procedure, by report |

Refer to Section II of the Medicaid Dental Provider Manual for service definitions, information regarding reimbursement, prior authorization and other information pertaining to orthodontic treatment.

|262.200 National Place of Service Codes |7-1-07 |

Refer to the appropriate Arkansas Medicaid Provider Manual for instructions.

|262.300 Billing Instructions – Paper Claims Only |10-13-03 |

Refer to the appropriate Arkansas Medicaid Provider Manual for instructions.

|262.400 Billing Procedures for Preventive Health Screens |9-1-14 |

ARKids First-B reimburses providers for preventive health screenings performed at the intervals recommended by the American Academy of Pediatrics.

References in this section indicate that ARKids First-B preventive health screenings are similar to Arkansas Medicaid Child Health Services (EPSDT) screens in content and application. However, please note this important distinction:

Claims for ARKids First-B preventive health screenings electronically or by paper must be billed in the CMS-1500 claim format.

NOTE: Certified nurse-midwives are restricted to performing the preventive health screen, Newborn, only, and must bill either code 99460, 99461 or 99463, with the required UA modifier, for initial newborn screen or codes 99221 or 99223 for newborn illness care.

A Certified nurse-midwife may NOT bill procedure codes 99381-99385 or 99391-99395 for child preventive health screens.

|262.410 Primary Care Physician Referral Requirements for Preventive Health Screens |2-1-10 |

All preventive health screens 99381-99385 or 99391-99395 for ARKids First-B beneficiaries must be provided by the primary care physician (PCP) of the beneficiary or by PCP referral to a qualified practitioner.

Newborn preventive health screens are exempt from the PCP referral requirement.

Immunizations for childhood diseases are exempt from the PCP referral requirement.

|262.420 Limitation on Laboratory Procedures Performed During a Preventive Health Screen |3-15-13 |

ARKids First-B preventive health screens will not include laboratory procedures unless the screen is performed by the beneficiary’s PCP, is conducted pursuant to a referral from the PCP or is included in the exceptions listed below.

Exceptions

The following tests are exempt from the above limitations and may continue to be billed in conjunction with a preventive health screen performed in accordance with existing Medicaid policy only if they are performed within seven (7) calendar days following the screen:

|81000 |81001 |81002 |83020 |83655 |

|85013 |85014 |85018 |86580 |95199 |

Claims for laboratory tests, other than those specified above, performed in conjunction with a preventive health screen will be denied unless the screen is performed by the PCP or pursuant to a referral from the PCP.

|262.430 Vaccines for ARKids First-B Beneficiaries |8-1-15 |

ARKids First-B beneficiaries are not eligible for the Vaccines for Children (VFC) Program; however, vaccines can be obtained to administer to ARKids First-B beneficiaries who are under the age of 19 by contacting the Arkansas Department of Health and indicating the need to order ARKids-B SCHIP vaccines. View or print the Department of Health contact information.

Only a vaccine injection administration fee is reimbursed. When filing claims for administering vaccines for ARKids First-B beneficiaries, providers must use the CPT procedure code for the vaccine administered and the required modifier SL only for either electronic or paper claims. Providers must bill claims for ARKids First-B beneficiaries using the CMS-1500 claim format.

The following list contains the SCHIP vaccines available to ARKids-First-B beneficiaries through the Arkansas Department of Health.

|Procedure Code |M1 |Age Range |

|90633 |SL |12 months-18 years |

|90634 |SL |12 months-18 years |

|90636 |SL |18 years only |

|90645 |SL |0-18 years |

|90646 |SL |0-18 years |

|90647 |SL |0-18 years |

|90648 |SL |0-18 years |

|90649 |SL |9-18 years |

|90650 |SL |9-18 years |

|90654 |SL |18 years |

|90655 |SL |6 months-35 months |

|90656 |SL |3 years-18 years |

|90657 |SL |6 months-35 months |

|90658 |SL |3 years-18 years |

|90660 |SL |2 years-18 years (not pregnant) |

|90669 |SL |0-4 years |

|90670 |SL |6 weeks-5 years |

|90672 |SL |2 years-18 years |

|90673 |SL |18 years |

|90680 |SL |6 weeks to 32 weeks |

|90681 |SL |6 weeks to 32 weeks |

|90685 |SL |6 months through 35 months |

|90686 |SL |3-18 years |

|90688 |SL |3-18 years |

|90696 |SL |4-6 years |

|90698 |SL |0-4 years |

|90700 |SL |0-6 years |

|90702 |SL |0-6 years |

|90707 |SL |0-18 years |

|90710 |SL |0-18 years |

|90713 |SL |0-18 years |

|90714 |SL |7-18 years |

|90715 |SL |7-18 years |

|90716 |SL |0-18 years |

|90720 |SL |0-18 years |

|90721 |SL |0-18 years |

|90723 |SL |0-18 years |

|90732 |SL |2-18 years |

|90734 |SL |0-18 years |

|90743 |SL |0-18 years |

|90744 |SL |0-18 years |

|90747 |SL |0-18 years |

|90748 |SL |0-18 years |

|262.431 Billing of Multi-Use and Single-Use Vials |11-1-15 |

Arkansas 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. If the dosage given is not a multiple of the number provided in the HCPCS code description, the provider shall round up to the nearest whole number in order to express the HCPCS description number as a multiple.

1. Single-Use Vials: If the provider must discard the remainder of a single-use vial or other package after administering the prescribed dosage of any given drug, Arkansas Medicaid will cover the amount of the drug discarded along with the amount administered.

2. Multi-Use Vials: 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 patient’s 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.

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