How to Fill Out and Submit the Arkansas Medicaid Prior Authorization Form

To complete an Arkansas Medicaid prior authorization form, identify which contractor reviews the service you’re requesting, download the correct form from Section V of the relevant provider manual on the Department of Human Services website, fill in the patient, provider, and clinical justification fields, and submit through the MMIS Provider Portal or the contractor’s own system. There is no single universal form, and sending a request to the wrong reviewer is the fastest way to lose days.

Pick the Right Form and the Right Reviewer

Arkansas Medicaid splits prior authorization work among three contractors. The Arkansas Foundation for Medical Care (AFMC) reviews surgical and inpatient procedures. Acentra Health handles home and community-based waiver services through its Atrezzo Portal.1Acentra Health. Arkansas Department of Human Services: Home Prime Therapeutics manages pharmacy requests for drugs not on the Preferred Drug List at ar.primetherapeutics.com.2Arkansas Department of Human Services. Pharmacy

Section V of every Arkansas Medicaid provider manual lists the current forms.3Arkansas Department of Human Services. Arkansas Medicaid Forms The most commonly used PA forms include:

  • DMS-679, Medical Equipment Request for Prior Authorization and Prescription, used for durable medical equipment.
  • DMS-679A, Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components.
  • DMS-102, CHMS Request for Prior Authorization, used for Community Health Management Services.
  • DMS-0101, Contact Lens Prior Authorization Request Form.

Surgical procedures, whether inpatient or outpatient, go through AFMC. The specific CPT codes that require AFMC prior authorization are listed in Section 262.000 of the Arkansas Medicaid Physician’s Provider Manual.4Arkansas Medicaid Review Services. Arkansas Medicaid Prior Authorization If you’re unsure which contractor handles your request type, Section II of your provider manual lists the routing instructions and contact information.5Arkansas Foundation for Medical Care. Arkansas Physician Medicaid Update Q1 SFY 2025

Arkansas Medicaid accepts electronic signatures on these forms. To use the digital signature field, download the form and open it in the Adobe Acrobat Reader desktop application rather than viewing it in a browser window.6Arkansas Department of Human Services. Section V Forms and Contacts

What to Have in Front of You Before You Start

Missing even one required field is a common reason requests stall or get kicked back. For surgical and medical procedure requests routed through AFMC, you’ll need:4Arkansas Medicaid Review Services. Arkansas Medicaid Prior Authorization

  • Patient full name, address with zip code, date of birth, and Medicaid number.
  • Admission date and planned procedure date.
  • Hospital or ambulatory surgery center name and its Medicaid provider number.
  • Medicaid provider number of the physician performing the procedure.
  • CPT code for each procedure, the principal diagnosis, and any secondary diagnoses.
  • Signs and symptoms of illness, plus a clear medical indication explaining why the procedure is necessary.

Note which provider identifier the submission requires. Electronic transactions through the MMIS portal use the National Provider Identifier (NPI) wherever a provider number is called for. Paper claims and forms use the Arkansas Medicaid Provider ID instead; paper submissions with only an NPI will be returned.7Arkansas Department of Human Services. National Provider Identifier (NPI) Information

The clinical justification field is where most requests succeed or fail. A bare diagnosis code won’t do it. Attach recent clinical notes, lab results, or imaging reports that directly address the coverage criteria in the Arkansas Medicaid Provider Manual for the specific service. If a less expensive alternative exists, say concretely why it won’t work for this patient. Reviewers look for that explanation and will deny the request without it.

Submit Through the MMIS Provider Portal

The Arkansas Medicaid Healthcare Provider Portal (MMIS) is the preferred submission method and gives real-time tracking after you submit.4Arkansas Medicaid Review Services. Arkansas Medicaid Prior Authorization From a single interface you can submit claims, check eligibility, upload documents, and file prior authorizations.8Arkansas Foundation for Medical Care. Arkansas Medicaid Management Information System Once logged in:9Arkansas Department of Human Services. Prior Authorization Job Aid

  1. Log in with your User ID and password, then click the Care Management tab.
  2. Click Create Authorization.
  3. Select State Medical, State Dental, or AFMC above the Process Type field, depending on the service category.
  4. Choose the correct Process Type from the dropdown and fill in all required fields (anything with a red asterisk).
  5. If you have supporting documents, scroll to the Attachments Panel, click the “+” to expand it, upload each file, and click Add. A yellow indicator flashes during upload and turns green when complete.
  6. Click Submit, then Confirm. The system generates a PA Tracking Number for monitoring the request.

Keep that tracking number. It’s your proof the request entered the system and the way to check pending, approved, or denied status through the portal.

Pharmacy Requests Through CoverMyMeds

Beginning August 1, 2025, Arkansas Medicaid accepts electronic pharmacy PA requests through CoverMyMeds. If real-time approval isn’t achieved there, the request goes to further clinical review, which can take up to one business day.10Arkansas Medicaid Portal. Arkansas Medicaid Prior Authorization Form A separate change effective January 1, 2026 altered the PA process for physician-administered drugs; Official Notice ON-034-25 on the DHS website has the details.

Phone and Alternate Portals

If portal access isn’t an option, AFMC takes PA requests by phone at 800-426-2234, Monday through Friday from 8:00 a.m. to 12:00 p.m. and 1:00 p.m. to 4:30 p.m., excluding holidays.4Arkansas Medicaid Review Services. Arkansas Medicaid Prior Authorization Acentra Health’s Atrezzo Portal is available 24/7 for the services it manages.1Acentra Health. Arkansas Department of Human Services: Home

Emergency Services Don’t Need Prior Authorization

Emergency hospital care is exempt from prior authorization and from PCP authorization requirements, so no advance approval is needed before stabilizing the patient.11Medicaid.gov. Arkansas State Plan Amendment 20-0013 If a patient is admitted through the emergency department and later needs non-emergency services that do require PA, submit the request as soon as the patient is stabilized. Waiting until discharge is one of the top claim denial triggers.

How Long a Decision Takes

Under federal Medicaid managed care rules effective for rating periods starting on or after January 1, 2026, the maximum turnaround for a standard prior authorization decision is seven calendar days from the date the request is received. Expedited decisions, reserved for situations where delay could seriously jeopardize the patient’s life, health, or ability to regain maximum function, must come within 72 hours.12eCFR. 42 CFR 438.210

Both timelines can be extended by up to 14 additional calendar days if the enrollee or provider requests the extension, or if the reviewing entity justifies a need for additional information and shows the extension serves the enrollee’s interest.12eCFR. 42 CFR 438.210 In practice, incomplete submissions are the most common reason a reviewer invokes that extension.

Why Requests Get Denied

Most PA denials fall into a handful of preventable categories. Clinically, insufficient documentation of medical necessity leads the list: the reviewer couldn’t find enough evidence in the records to justify the service under Medicaid policy. Administratively, three claim-level errors show up again and again:

  • No PA on file. The service was performed before authorization was obtained, or the request was never submitted.
  • Revenue code mismatch. The revenue codes on the claim don’t match what was authorized on the PA.
  • Date of service mismatch. The dates on the claim fall outside the authorized service dates.

Those last three are entirely avoidable. Before performing the service, confirm the PA is approved and note the exact authorized dates and revenue codes. When you file the claim, match those fields precisely.

A note on how reviews run: at AFMC, a registered nurse Clinical Services Specialist screens the request first and can approve it on the spot if the documentation supports medical necessity. If not, the case gets bumped to an Arkansas-licensed physician advisor, which adds days.4Arkansas Medicaid Review Services. Arkansas Medicaid Prior Authorization Clinical notes that map directly to the coverage criteria, with clear documentation of why alternatives were ruled out, give the nurse what she needs to approve without escalating.

If Your Request Is Denied

Provider Reconsideration

If AFMC denies a prior authorization, the provider has 35 calendar days from the date on the denial letter to request reconsideration. The request must be in writing and include a copy of the denial letter along with additional documentation supporting medical necessity. Requests received after the 35-day window will not be accepted.4Arkansas Medicaid Review Services. Arkansas Medicaid Prior Authorization

Reconsideration is the chance to fill the gap the reviewer identified. A request that simply restates the original justification without new evidence rarely succeeds. Add the missing lab results, specialist consultation notes, or documentation of failed alternative treatments that the first submission lacked.

Beneficiary Fair Hearing

The Medicaid beneficiary, not just the provider, has the right to challenge a denial. Under Arkansas Code ยง 20-77-121, whenever a claim or application for medical assistance is denied in whole or in part, DHS must send written notice explaining the adverse action, the specific facts behind it, and the beneficiary’s right to a fair hearing under the Arkansas Administrative Procedure Act.13Justia Law. Arkansas Code Title 20 – Section 20-77-121 – Adverse Decisions – Notice

The fair hearing request must be submitted in writing to the Appeals and Hearings Section of DHS within 35 calendar days of the denial letter’s date.4Arkansas Medicaid Review Services. Arkansas Medicaid Prior Authorization Beneficiaries can represent themselves, hire legal counsel, or have a friend or other spokesperson (other than a corporation) act for them. To file, complete and return the back side of the Notice of Action letter, or submit a separate written request. DHS provides Form DHS-1200 for this purpose, and county office staff can help fill it out.14Arkansas Department of Human Services. File an Appeal

When the denial involves a medical necessity determination, the notice must specify which medical records the clinician relied on and which coverage criteria the beneficiary did not meet. Generic rationales don’t satisfy that requirement; the denial must address the individual patient’s circumstances.13Justia Law. Arkansas Code Title 20 – Section 20-77-121 – Adverse Decisions – Notice A vague or boilerplate denial letter can itself be grounds for challenging the decision at the hearing.