DMS CHMS Benefit Extension for Diagnosis/Evaluation Procedures

DIVISION OF MEDICAL SERVICES

CHMS BENEFIT EXTENSION FOR DIAGNOSIS/EVALUATION PROCEDURES

PROVIDER NAME: (1) / ADDRESS: (2)
PROVIDER PHONE AND FAX #: (3) / PROVIDER ID NUMBER/TAXONOMY CODE: (4)
BENEFICIARY’S LAST NAME: (5) / FIRST: (6) / M.I.: (7)
BENEFICIARY’S MEDICAID ID #: (8) / DATE OF BIRTH: (9) / SEX: (10)
MALE FEMALE
PARENT/GUARDIAN NAME: (11) / BENEFICIARY’S PHONE NUMBER HOME/MESSAGE: (12)
MAILING ADDRESS (Street, P.O. Box, City, State, and Zip Code): (13) / COUNTYRESIDENCE: (14)
PCP NAME: (15) / PCP PROVIDER ID #/TAXONOMY CODE: (16)
PRIMARY DIAGNOSIS: (17) / SECONDARY DIAGNOSIS: (18) / OTHER DIAGNOSIS: (19)

B.

CHMS DIAGNOSTIC/

EVALUATIONDATE OF SERVICE

PROCEDURE CODE OR EXPECTED DATEREQUESTED

REQUESTED (20)OF SERVICE (21)UNITS (22)

BRIEF MEDICAL SUMMARY: (23)

ATTACH MEDICAL RECORDS TO SUBSTANTIATE MEDICAL NECESSITY

Provider’s Signature: (24) ______Date: (25) ______

Please retain a copy of this form in your files. Send completed form to:

Arkansas Foundation for Medical Care, Inc.

P.O. Box 180001

Fort Smith, AR72918

Fax # (479) 649-0776

Completion of AFMC CHMS Benefit Extension for Diagnosis/Evaluation Procedures

Section A – To be completed by the provider requesting prior authorization.

Item 1 – Provider Name: Write the name of the Medicaid provider requesting benefit extension.

Item 2 – List the mailing address of the Medicaid provider requesting benefit extension. Include the nine-digit zip code number.

Item 3 – List the area code, telephone number, and fax number of the Medicaid provider requesting the benefit extension.

Item 4 – List the provider identification number and taxonomy code of the Medicaid provider requesting the benefit extension.

Item 5 – Beneficiary’s Last Name: Enter the beneficiary’s last name.

Item 6 – First Name: Enter the beneficiary’s first name.

Item 7 – Middle Initial: Enter the beneficiary’s middle initial.

Item 8 – Enter the beneficiary’s ten (10) digit Medicaid ID number.

Item 9 – Enter the beneficiary’s month, day and year of birth. (MM/DD/YYYY).

Item 10 – Check (M) for Male – (F) for Female.

Item 11 – Enter the last name, first name and middle initial of the parent or guardian. Circle whether parent or guardian.

Item 12 – Enter the area code, home telephone number, if available, or a message telephone number. Circle whether a home or message number.

Item 13 – Enter beneficiary’s mailing address. Include the nine-digit zip code.

Item 14 – Enter the county in which the beneficiary resides.

Item 15 – Enter the name of the beneficiary’s Primary Care Physician. If the beneficiary is exempt from PCP requirement, enter the name of the attending physician.

Item 16 – Enter the provider identification number and taxonomy code of the Primary Care Physician.

Item 17 – Enter the ICD Diagnosis Code and nomenclature representing the patient’s primary condition or symptom requiring or contributing to the need for the prescribed procedure codes.

Item 18 – Enter the ICD Diagnosis Code and nomenclature representing the patient’s secondary condition or symptom requiring or contributing to the need for the prescribed procedure codes.

Item 19 – Enter a tertiary ICD Diagnosis Code, if applicable.

Section B:

Item 20 – Enter the diagnosis/evaluation procedure code(s) requested. Refer to Section II of this manual for appropriate codes.

Item 21 – Enter the requested date of service.

Item 22 – Enter the number of units requested for each procedure code.

Item 23 – Write a brief medical summary. NOTE: Attach medical records to substantiate medical necessity of extension of benefits for each procedure code requested.

Item 24 – Request must be signed by the provider requesting extension of benefits or by the provider’s authorized representative.

Item 25 – Date of the signature by the provider requesting extension of benefits.

DMS-699-A (12-15-14)