MedicaidCoverageHigh impact
REVISED New Coverage - Presumptive Eligibility – Pregnant Women (PE-PW)
Arkansas Medicaid·AR · OB-GYN, Family Medicine, Internal Medicine +1 more·Claims & Billing
Effective date
Jun 1, 2025
We identified it
Jul 2, 2025
Summary
Effective June 1, 2025, Arkansas Medicaid is launching Presumptive Eligibility for Pregnant Women (PE-PW), a new temporary coverage category providing immediate prenatal care and pregnancy-complication services in outpatient settings before full eligibility determination. Billing teams must update claims to include pregnancy as primary/secondary diagnosis, remove prior authorization requirements, waive copays, and eliminate PCP referral requirements for PE-PW members.
Action Required
By June 1, 2025: (1) Billing team must update billing system to recognize PE-PW as a valid Medicaid aid category and configure it to waive prior authorization requirements for all prenatal and pregnancy-complication services. (2) Modify claim submission rules to require pregnancy diagnosis (ICD-10 code from O00-O9A range) as primary or secondary diagnosis on all institutional, professional, and dental claims for PE-PW members—transportation claims (provider type 15) are exempt. (3) Update fee schedules to eliminate copay collection for PE-PW members. (4) Configure system to NOT require PCP referrals for PE-PW encounters. (5) Enable Non-Emergency Transport (NET) services eligibility for PE-PW members. (6) Train front-desk, billing, and provider staff on PE-PW eligibility criteria and that inpatient services are excluded from this coverage. (7) Verify encounter forms prompt providers to document pregnancy diagnosis. Failure to comply will result in claim denials, member balance issues, and compliance violations with Arkansas DHS.