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Click ‘Get Form’ to open the Arkansas Medicaid PA form in our editor.
Begin by filling out the Requestor Name and Title at the top of the form. Ensure this information is complete and legible to avoid delays.
In the Beneficiary Information section, enter the LAST NAME, FIRST NAME, MEDICAID ID NUMBER, and DATE OF BIRTH. This information is crucial for processing your request.
Next, provide the Prescriber Information including LAST NAME, FIRST NAME, NPI NUMBER, DEA NUMBER, PHONE NUMBER, and FAX NUMBER. Accurate details here are essential for verification.
In the Medication Requested section, list the drug name and strength. If applicable, ensure you follow any additional instructions regarding specific medications like Hepatitis C treatments.
Attach a letter of Medical Necessity along with any supporting documentation such as chart notes or lab results to assist in your prior authorization process.
Finally, ensure that the Prescriber Signature is included; original signatures are required. Date the form before submission.

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What is Medicaid called in Arkansas?

ARHOME is a Medicaid program that offers eligible Arkansans private health insurance coverage.

Is Arkansas home the same as Medicaid?

Other Important Numbers Arkansas Medicaid Claims Questions Information Line (coverage, bills, beneficiary denial letters, or other services)1-800-482-5431 Arkansas Medicaid Complaint Hotline (for complaints about healthcare) 1-888-987-12002 more rows

What is Arkansas Medicaid called?

All out-of-network services require prior authorization except emergency care, out-of-area urgent care, and out-of-area dialysis. Failure to complete the required authorization or certification may result in a denied claim.

What documents are needed for Medicaid in Arkansas?

0:30 2:09 Its like packing for a trip but to the land of Health Care coverage. Once youve applied wait forMoreIts like packing for a trip but to the land of Health Care coverage. Once youve applied wait for the response. Its like waiting for a golden ticket. But for health services.

What is the Arkansas Medicaid line?

0:22 1:59 First up we have the traditional Medicaid. This ones the original program it covers hospital visitsMoreFirst up we have the traditional Medicaid. This ones the original program it covers hospital visits doctor appointments. And even long-term Medical Care.