MedicaidCoverageHigh impact
Physical and Occupational Therapy Coverage for Adults in a Clinic Setting
Arkansas Medicaid·AR · Physical Therapy, Occupational Therapy·Claims & Billing
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Arkansas Medicaid expanded coverage for Physical and Occupational Therapy services for adults in clinic settings effective July 1, 2026, establishing new visit limits (12 combined OT/PT visits per state fiscal year, 2 evaluations each per type), introducing specific HCPCS billing codes with modifiers, and requiring prior authorization for benefit extensions through AFMC using process type 126.
Action Required
By July 1, 2026: (1) Billing team must configure billing system to enforce service limits under code 5109 (12 ADULT THERAPY PROCEDURES PER SFY) and track two evaluation maximums per therapy type per state fiscal year. (2) Update CMS-1500 paper claim submission process to require Box 17 entry of Specialist MCD ID and Box 19 entry of 'F' modifier for adult therapy claims. (3) Train billing staff on modifier usage (UB, U1, U2) for correct code selection based on provider type (PT, PTA, OT, OTA). (4) Establish procedure for benefit extension requests: obtain Medical Assistance Remittance (RA) and Status Report showing exhausted benefits denial, submit within 90 calendar days to AFMC via process type 126 with supporting clinical documentation; failure to provide requested information within specified timeframe results in technical denial. (5) Configure system to monitor limit audit 5109 availability (expected mid-to-late July 2026); hold claims analysis until audit is active per RA notification. (6) Update portal access instructions for providers to view member therapy usage under Service Limit section for code 5109. Failure to enforce visit limits will result in claim denials beyond benefit maximums; failure to submit benefit extension requests within 90 days will result in permanent denials.