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 or 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. Benefit extension requests will be considered only when the provider has correctly completed all applicable fields of the “Request for Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services” Form DMS-671. View or print form DMS-671.
C. The date of the request and the signature of the provider's authorized representative are required on the form. Stamped or electronic signatures are accepted.
D. Dates of service must be listed in chronological order on Form DMS-671. When requesting benefit extensions for more than four (4) procedures, use a separate form for each set of procedures.
E. Enter a valid ICD diagnosis code and a brief narrative description of the diagnosis.
F. Enter a valid procedure code or revenue code, modifier(s) when applicable and a brief narrative description of the procedure.
G. Enter the number of units of service requested under the extension.
Credits
Eff. Nov. 1, 2007; Oct. 13, 2003; Feb. 1, 2005; May 1, 2008; June 15, 2006. Amended July 15, 2012; July 1, 2014; Dec. 15, 2014; 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 016.06.3-215.121, AR ADC 016.06.3-215.121
