016.06.05 Ark. Code R. § 021 Arkids First-B Update Transmittal #23

• Library: Arkansas Administrative Code
• Edition: 2023
• Currency: Current through Register Vol. 48, No. 12, December, 2023
• Citation: 016.06.05 Ark. Code R. § 021
• Year: 2023

Section II ARKids First-B

223.100 Procedure for Extension of Benefits A. Medical Supplies To request a benefit extension for medically necessary medical supplies; submit form DMS-699, Request for Extension of Benefits, a completed ARKids First-B claim and additional medical records, if needed, to substantiate medical necessity to the Division of Medical Services Utilization Review Section. View or print the Division of Medical Services Utilization Review Section address. The Benefit Limit Review Committee, which includes medical personnel, will review the medical records and notify the requesting provider of the approval or denial of the request. The approved notice will contain an authorization number that must be shown on the claim. B. Speech Therapy If the provider determines the recipient needs more speech therapy services than those allowed in the Occupational, Physical, Speech Therapy Provider Manual, a form DMS-671, Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services, must be completed and sent to the Arkansas Foundation for Medical Care. View or print AFMC contact information. View or print form DMS-671.

262.110 Medical Supplies Procedure Codes The following medical supplies procedure codes may be billed by Medicaid-enrolled Home Health and Prosthetics providers for ARKids First participants. Type of service codes are used only when billing on paper.

A4206	A4221	A4222	A4253 U1	A4256
A4259 U2	A4265	A4310	A4311	A4312
A4313	A4314	A4315	A4316	A4320
A4322	A4326	A4327	A4328	A4330
A4338	A4340	A4344	A4346	A4348
A4351	A4352	A4354	A4355	A4356
A4357	A4358	A4359	A4361	A4362
A4364	A4367	A4369	A4371	A4397
A4398	A4399	A4400	A4402	A4404
A4405	A4406	A4450	A4452	A4455
A4558	A4561	A4562	A4623	A4624
A4625	A4626	A4628	A4629	A4772
A4927	A5051	A5052	A5053	A5054
A5055	A5061	A5062	A5063	A5071
A5072	A5073	A5081	A5082	A5093
A5102	A5105	A5112	A5113	A5114
A5119	A5121	A5122	A5126	A5131
A6154	A6234	A6241	A6242	A6248
A7520	B4086	E0776

Procedure Code	Required Modifier	Description
A6257	-	Transparent film, each (16 square inches or less)
A6258	-	Transparent film, each (more than 16, but less than 48 square inches)
A6259	-	Transparent film, each (more than 48 square inches)
A6216 A6219 A6228	"	Gauze pads medicated or non-medicated, each (16 square inches or less)
A6217 A6220 A6229 A6403	Gauze pads medicated or non-medicated, each (more than 16, but less than 48 square inches)
A6204 A6218 A6221 A6230	Gauze pads medicated or non-medicated, each (more than 48 square inches)

A6441 A6446	-	Gauze, non-elastic, per roll (1 linear yard)
A6242 A6245	-	Hydrogel dressing, each (16 square inches or less)
A6243 A6246	-	Hydrogel dressing, each (more than 16, but less than 48 square inches)
A6244 A6247	-	Hydrogel dressing, each (more than 48 square inches)
A6248	-	Hydrogel dressing, each (1 ounce)
A6234 A6237	-	Hydrocolloid dressing, each (16 square inches or less)
A6235 A6238	-	Hydrocolloid dressing, each (more than 16, but less than 48 square inches)
A6238	U1	Hydrocolloid dressing, each (more than 48 square inches)
A6196	-	Alginate dressing, each (16 square inches or less)
A6197	-	Alginate dressing, each (more than 16, but less than 48 square inches)
A6198	-	Alginate dressing, each (more than 48 square inches)
A6197	-	Alginate dressing, each (1 linear yard)
A6209 A6212	-	Foam dressing, each (16 square inches or less)
A6210 A6213	-	Foam dressing, each (more than 16, but less than 48 square inches)
A6211	-	Foam dressing, each (more than 48 square inches)
A6200 A6203	-	Composite dressing, each (16 square inches or less)
A6201 A6204	-	Composite dressing, each (more than 16, but less than 48 square inches)
A6202 A6205	-	Composite dressing, each (more than 48 square inches)
A4253	-	Blood glucose test or reagent strips for home blood glucose monitor, per 25 strips
A4353	-	Urinary intermittent catheter with insertion tray
A4394	-	Ostomy deodorant, all

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