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016.06.2-214.110. Completion of Form DMS-671, “Request For Extension of Benefits for Clinical, ...

AR ADC 016.06.2-214.110Arkansas Administrative CodeEffective: July 1, 2022

West's Arkansas Administrative Code
Title 016. Department of Human Services
Division 06. Division of Medical Services
Rule 2. Chiropractic Provider Manual (Refs & Annos)
Section 210.000. Program Coverage
Effective: July 1, 2022
Ark. Admin. Code 016.06.2-214.110
016.06.2-214.110. Completion of Form DMS-671, “Request For Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services”
Currentness
A. The Medicaid Program's diagnostic laboratory services benefit limit and radiology/other services benefit limit each apply to the outpatient setting.
1. Diagnostic laboratory services benefits are limited to five hundred dollars ($500) per State Fiscal Year (SFY: July 1 through June 30), and radiology/other services benefits are limited to five hundred dollars ($500) per SFY.
2. Radiology/other services include without limitation diagnostic X-rays, ultrasounds, and electronic monitoring/machine tests, such as electrocardiograms (ECG or EKG).
3. Diagnostic laboratory services and radiology/other services defined as Essential Health Benefits by the U.S. Preventive Services Task Force (USPSTF) are exempt from counting toward either of the two new annual caps.
View or print the essential health benefit procedure codes.
B. Requests for extension of benefits for clinical services (physician's visits), outpatient services (hospital outpatient visits), laboratory services (diagnostic laboratory tests), and radiology/other services must be submitted to DHS or its designated vendor for consideration.
View or print contact information to obtain the DHS or designated vendor step-by-step process for requesting extension of benefits.
Consideration of requests for extension of benefits requires correct completion of all fields on the “Request for Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services: form (Form DMS-671). View or print form DMS-671.
Complete instructions for accurate completion of Form DMS-671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each Provider Manual.

Credits

Eff. Nov. 1, 2006; Oct. 13, 2003. Amended July 1, 2007; Aug. 1, 2021; July 1, 2022.
<Editor’s Note: Nonfunctioning links so in original.>
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 016.06.2-214.110, AR ADC 016.06.2-214.110
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