Therapy (PT/OT/ST and EIDT/ADDT) DMS - 640

1. Therapy (PT/OT/ST and EIDT/ADDT)DMS - 640 2019

2. Therapy Procedure Codes

3. Required Documentation • DMS – 640 • ○Start and end dates of the PA request must align with the DMS-640 • ○If the requested PA date range falls outside of the DMS-640, look or ask for an additional DMS-640 to cover entire requested date range. • Current evaluation • ○Must be dated and signed by a therapist within the last 12 months • Current Plan of Treatment • ○Must be signed and dated by a therapist within the last 12 months. • ○ Must include short term and functional goals and preferably a long term goal.

4. DMS-640 Example

5. DMS – 640 Instructions

6. Form Requirements • Form must be filled out completely • Must have Physician Signature • Form must have a date within the last 12 months • Form CANNOT be altered in any way • Please use state form • Attach document in provider portal at time of request • Additional information is included in the Medicaid Provider Manual

7. AR Website Forms • http://ar.eqhs.org/News-and-Resources

8. Medicaid Provider Manual Link • https://medicaid.mmis.arkansas.gov/Provider/Docs/Docs.aspx

9. Contact Information - Provider Education Ar.pr@eqhs.org 501-725-9411 Amelia White Issac Richardson awhite@eqhs.orgirichardson@eqhs.org 501-725-9412 501-725-9415 Toll free – 888-860-3831 Toll free fax line – 855-997-3707

10. Questions?