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016.06.36-225.000. Outpatient Hospital Benefit Limit

AR ADC 016.06.36-225.000Arkansas Administrative CodeEffective: October 7, 2022

West's Arkansas Administrative Code
Title 016. Department of Human Services
Division 06. Division of Medical Services
Rule 36. Physician/Independent Lab/Crna/Radiation Therapy Center Provider Manual (Refs & Annos)
Section 224.000. Inpatient Hospital Services.
Effective: October 7, 2022
Ark. Admin. Code 016.06.36-225.000
016.06.36-225.000. Outpatient Hospital Benefit Limit
Currentness
Medicaid-eligible clients twenty-one (21) years or older are limited to a total of twelve (12) outpatient hospital visits a year. This benefit limit includes outpatient hospital services provided in an acute care, general, or a rehabilitative hospital. This yearly limit is based on the State Fiscal Year (SFY/July 1 through June 30).
A. Outpatient hospital services include the following:
1. Non-emergency professional visits in the outpatient hospital and related physician, advanced practice registered nurse (APRN), and physician assistant services.
2. Outpatient hospital therapy and treatment services and related physician, APRN, and physician assistant services.
B. Extension of benefits will be considered for clients based on medical necessity.
C. The Arkansas Medicaid Program automatically extends the outpatient hospital visit benefit for certain primary diagnoses. Those diagnoses are:
1. Malignant neoplasm (View ICD Codes.)
2. HIV infection and AIDS (View ICD Codes.)
3. Renal failure (View ICD Codes.)
4. Pregnancy (View ICD Codes.)
5. Opioid Use Disorder when treated with MAT (View ICD OUD Codes.)
D. When a Medicaid eligible client's primary diagnosis is one (1) of those listed above and the Medicaid eligible client has exhausted the Medicaid established benefit limit for outpatient hospital services and related physician, APRN, and physician assistant services, the provider does not have to file for an extension of the benefit limit.
E. All outpatient hospital services for clients under age twenty-one (21) in the Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program are not benefit limited.
F. Emergency and surgical physician services provided in an outpatient hospital setting are not benefit limited.

Credits

Eff. Feb. 1, 2006. Amended Sept. 1, 2020; Oct. 7, 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 016.06.36-225.000, AR ADC 016.06.36-225.000
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