section vof all provider billing manuals（部分受到所有供应商账单手册）（8页）.docVIP

section V – FORMS 500.000 Claim Forms Red-ink Claim Forms The following is a list of the red-ink claim forms required by Arkansas Medicaid. The forms below cannot be printed from this manual for use. Information about where to get the forms and links to samples of the forms is available below. To view a sample form, click the form name. Claim Type Where To Get Them Professional – CMS-1500 Business Form Supplier Institutional – CMS-1450* Business Form Supplier Visual Care – DMS-26-V 1-800-457-4454 Inpatient Crossover – HP-MC-001 1-800-457-4454 Long Term Care Crossover – HP-MC-002 1-800-457-4454 Outpatient Crossover – HP-MC-003 1-800-457-4454 Professional Crossover – HP-MC-004 1-800-457-4454 * For dates of service after 11/30/07 – ALL HOSPICE PROVIDERS USE ONLY FORM CMS-1450 (formerly UB-04) for billing. Claim Forms The following is a list of the non-red-ink claim forms required by Arkansas Medicaid. Information about where to get a supply of the forms and links to samples of the forms is available below. To view a sample form, click the form name. Claim Type Where To Get Them Alternatives Attendant Care Provider Claim Form – AAS-9559 Client Employer Dental – ADA-J430 Business Form Supplier Arkansas Medicaid Forms The forms below can be printed from this manual for use. In order by form name: Form Name Form Link Acknowledgement of Hysterectomy Information DMS-2606 Address Change Form DMS-673 Adjustment Request Form – Medicaid XIX HP-AR-004 Adjustment Request Form – Medicaid XIX – Pharmacy Program DMS-802 Adverse Effects Form DMS-2704 AFMC Prescription Prior Authorization Request for Medical Equipment Excluding Wheelchairs Wheelchair Components DMS-679A Amplification/Assistive Technology Recommendation Form DMS-686 Application for WebRA Hardship Waiver DMS-7736 Approval/Denial Codes for Inpatient Psychiatric Services DMS-2687 Arkansas Early Intervention Infant Toddler Program Intake/Referral/Application for Services DDS/FS#00