Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.17-022 - SecIII-1-17; SecI-2-17; SecV-3-17

Universal Citation: AR Admin Rules 016.06.17-022

Current through Register Vol. 49, No. 9, September, 2024

Section I

141.000 Provider Enrollment

Any provider of health care services must be enrolled in the Arkansas Medicaid Program before Medicaid will cover any services provided by the provider to Arkansas Medicaid beneficiaries. Enrollment as a Medicaid provider is contingent upon the provider satisfying all rules and requirements for provider participation as specified in the applicable provider manual, state and federal law. Persons and entities that are excluded or debarred under any state or federal law, regulation or rule are not eligible to enroll, or to remain enrolled, as Medicaid providers.

All providers must sign all applicable forms that require a signature and the Arkansas Medicaid Provider Contract. The signature must be an original signature or an approved electronic signature of the individual provider. The provider's authorized representative may sign the contract for a group practice, hospital, agency or other institution.

In addition to the information in Section 140.000, Section II of each program's provider manual may contain supplemental provider type specific participation requirements. The provider enrollment functions for the Arkansas Medicaid Program are performed by an independent contractor. The contractor is responsible for provider enrollment services for new providers and changes to current provider enrollment files. Potential providers must complete all appropriate portions of a provider enrollment Application Packet to execute the provider contract. They must also submit a copy of all certifications and licenses verifying compliance with enrollment criteria for the applicable provider fype or discipline to be practiced and pay the application fee (if applicable). See Section 141.101 for Application Fees.

Potential providers may enroll on the Arkansas Medicaid website at

https://www.medicaid.state.ar.us. Potential providers that are not required to pay application fees may also send the printed fomi to the Medicaid Provider Enrollment Unit. View or print the Provider Enrollment contact information.

All subsequent state license and certification renewals must be forwarded to the Medicaid Provider Enrollment Unit within 30 days of issuance. If the renewal document(s) have not been received within this timeframe, the provider will have an additional and FINAL 30 days to comply. Failure to timely submit verification of license or certification renewals will result In cancellation of enrollment in the Arkansas Medicaid Program. View or print the provider enrollment and contract package fApplication Packet).

In addition to the submission of the Application Packet, the following fonns are required and must be submitted to complete the enrollment process:

A. W-9 Tax form (DMS-652)

B. Medicaid Provider Contract (DMS-652)

C. PCP Agreement, if applicable (DMS-2608. See Section 171.000 for PGP requirements.)

D. EPSDT Agreement, if applicable (DMS-831. See Section 201.000 of the EPSDT provider manual for the EPSDT Agreement.)

E. Group Affiliation form, if applicable (DMS-652). This forni is applicable for individual providers who choose to authorize a group to bill and receive reimbursement on their behalf.

F. Authorization for Electronic Funds Transfer (Automatic Deposit)

Each provider must notify the Medicaid Provider Enrollment Unit in writing immediately regarding any changes to its application or contract status, such as:

A. Group Affiliation form, if applicable (DMS-652). This form is applicable for individual providers who choose to authorize a group to bill and receive reimbursement on their behalf.

B. Change in Federal Employer Identification Number (FEIN) may require the completion of a new enrollment application

C. Authorization for Electronic Funds Transfer (Automatic Deposit)

D. Change in practice or specialty

E. Retirement or death of provider

F. Name Change Form

G. Change of Ownership Form (DMS-0688) (View or print form DMS-0688 - Provider Change of Ownership Information Form.)

H. Address/Email Change Form (DMS-673) (View or print form DMS-673 - Address/Email Change Form.) NOTE: An active email address is required.

I. Change in Ownership Control (5% or more) or Conviction of Crime (View or print form DMS-675 - Ownership and Conviction Disclosure.)

J. Disclosure of Significant Business Transactions (View or print form DMS-689 -Disclosure of Significant Business Transactions.)

When the provider has successfully met all requirements, the Medicaid Provider Enrollment Unit will assign a unique Medicaid number to the provider. The assigned provider number is linked to the provider's tax identification number (either a Social Security Number or a Federal Employer Identification Number) and to the provider's National Provider Identifier (NPI) unless the provider is an atypical provider not required to have an NPI.

Section III

311.100 Electronic Funds Transfer (EFT)

Electronic Funds Transfer (EFT) allows providers to have their Medicaid payments automatically deposited. Effective 11/1/17, Arkansas i\/ledicaid no longer mails paper checks for Medicaid payment. Providers are required to submit a completed Authori2ation for ElectnDnic Funds Transfer (Automatic Deposit) form with their enrollment application. Provider Enrollment will deny applications that do not include a completed Authorization for Electronic Funds Transfer (Automatic Deposit) form. View or print the Authorization for Electronic Funds Transfer (Automatic Deposit) form.See Section I of the provider manual for additional infomiation regarding participation requirements.

SECTION V -FORMS 500.000

Cfaim Forms

Red-ink Claim Forms

The following is a list of tine red-ink claim forms required by Arkansas Medicaid. The forms below cannot be printed from tliis manual for use. Information about where to get the fonns and links to samples of the forms is available below. To view a sample fomi, click the form name.

Claim Type	Where To Get Them
Professional - CMS-1500	Business Form Supplier
Institutional - CMS-1450*	Business Fomri Supplier
Visual Care - DMS-26-V	1-800-457-4454
Inpatient Crossover- HP-MC-001	1-800-457-4454
Lona Term Care Crossover- HP-MC-002	1-800-457-4454
Outpatient Crossover - HP-MC-003	1-800-457-4454
Professional Crossover- HP-MC-004	1-800-457-4454

* For dates of service after 11/30/07 - ALL HOSPICE PROVIDERS USE ONLY FORM CMS-1450 (fomierly UB-04) for billing.

Claim Forms

The following is a list of the non-red-ink claim fomris required by Arkansas Medicaid. Information about where to get a supply of the forms and links to samples of the fonns is available below. To view a sample form, click the forni name.

Claim Type	Where To Get Them
Alternatives Attendant Care Provider Claim Form -AAS-9559	Client Employer
Dental-ADA-J430	Business Form Supplier

Arkansas Medicaid Forms

The fomis below can be printed from this manual for use.

In order by form name:

Form Name	Form Link
Acknowledgement of Hysterectomy Information	DMS-2606
Address/Email Change Form	DMS-673
Adjustment Request Form - Medicaid XIX	HP-AR-004
Adjustment Request Form - Medicaid XIX - Pharmacy Program	DMS-802
Adverse Effects Form	DMS-2704
AFMC Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelcfiairs & Wheelchair Components	DMS-679A
Amplification/Assistive Technology Recommendation Fonn	DMS-686
Application for WebRA Hardship Waiver	DMS-7736
Approval/Denial Codes for Inpatient Psychiatric Services	DMS-2687
Arkansas Eariy Intervention Infant & Toddler Program Intake/Referral/Application for Services	DDS/FS#0001.a
Arkansas Medicaid Patient-Centered Medical Home Program Practice Participation Agreement	DMS-844
Arkansas Medicaid Patient-Centered Medical Home Program Practice Update/Change Request Form	DMS-801
Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Form	DMS-845
Arkansas Medicaid Patient-Centered Medical Home Program Practice Withdrawal Form	DMS-846
ARKids First Behavioral Health Services Provider Qualification Form	DMS-612
Authorization for Electronic Funds Transfer (Automatic Deposit)	autodeDosit
Authorization for Payment for Sen/ices Provided	MAP-8
Certification of Need - Medicaid Inpatient Psychiatric Services for Under Age 21	DMS-2633
Certification of Schools to Provide Comprehensive EPSDT Services	CSPC-EPSDT
Certification Statement for Abortion	DMS-2698
Change of Ownership Information	DMS-0688
Child Health Management Services Enrollment Orders	DMS-201
Child Health Management Services Discharge Notification Form	DMS-202
CHMS Benefit Extension for Diagnosis/Evaluation Procedures	DMS-699A
CHMS Request for Prior Authorization	DMS-102
Claim Correction Request	DMS-2647
Consent for Release of Information	DMS-619
Contact Lens Prior Authorization Request Form	DMS-0101
Contract to Participate in the Arkansas Medical Assistance Program	DMS-653
DDTCS Transportation Log	DMS-638
DDTCS Transportation Survey	DMS-632
Dental Treatment Additional Infonnation	DI\/IS-32-A
Disclosure of Significant Business Transactions	DMS-689
Disproportionate Share Questionnaire	DMS-628
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Prescription/Referral For Medically Necessary Sen/ices/Items Not Specifically Included in the Medicaid State Plan	DMS-693
Early Childhood Special Education Referral Form	ECSE-R
EPSDT Provider Agreement	DMS-831
Explanation of Check Refund	HP-CR-002
Gail Analysis Full Body	DWIS-647
Home Health Certification and Plan of Care	CMS-485
Hospital/Physician/Certified Nurse-Midwife Refen-al for Newborn Infant Medicaid Coverage	DCO-645
Inpatient Psychiatric Medicaid Agency Review Team Transmittal Sheet	DMS-2685
Individual Renewal Form for School-Based Audiologists	DMS-7782
Lower-Limb Prosthetic Evaluation	DMS-650
Lower-Limb Prosthetic Prescription	DMS-651
Media Selection/Email Address Change Form	HP-MS-005
Medicaid Claim Inquiry Form	HP-CI-003
Medicaid Form Request	HP-MFR-001
Medical Equipment Request for Prior Authorization & Prescription	DMS-679
Medical Transportation and Personal Assistant Verification	DMS-616
Mental Health Sen/ices Provider Qualification Form for LCSW, LMFT and LPC	DMS-633
Notice Of Noncompliance	DMS-635
NPI Reporting Form	DMS-683
Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21 Prescription/Referral	DMS-640
Ownership and Conviction Disclosure	DWIS-675
Personal Care Assessment and Service Plan	DMS-618Enaltsh DMS-618 Spanish
Practitioner Identification Number Request Forni	DMS-7708
Prescription & Prior Authorization Request For Nutrition Therapy & Supplies	DMS-2615
Primary Care Physician Managed Care Program Referral Form	DMS-2610
Primary Care Physician Participation Agreement	DMS-2608
Primary Care Physician Selection and Change Form	DMS-2609
Procedure Code/NDC Detail Attachment Form	DMS-664
Provider Application	DMS-652
Provider Communication Form	AAS-9502
Provider Data Sharing Agreement - Medicare Parts C & D	DMS-652-A
Provider Enrollment Application and Contract Package	ADDlication Packet
Quarterly Monitoring Fonm	AAS-9506
Referral for Audiology Services - School-Based Setting	DMS-7783
Refen-a! for Certification of Need Medicaid Inpatient Psychiatric Services for Under Age 21	DMS-2634
Referral for Medical Assistance	Dn/IS-630
Request for Appeal	DMS-840
Request for Extension of Benefits	DMS-6g9
Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services	DMS-671
Request for Extension of Benefits for Medical Supplies for Medicaid Beneficiaries Under Age 21	DMS-602
Request for Molecular Pathology Laboratory Services	DMS-841
Request for Orthodontic Treatment	DMS-32-0
Request for Prior Approval for the Special Phannacy Therapeutic Agents and Treatments	DMS-6
Request for Private Duty Nursing Services Prior Authorization and Prescription - Initial Request or Recertification	DMS-2692
Request for Targeted Case Management Prior Authorization for Beneficiaries Under Age 21	DMS-601
Research Request Form	HP-0288
Sen/ice Log - Personal Care Delivery and Aides Notes	DMS-873
Sterilization Consent Fomn	DMS-615Enalish DMS-615 Spanish
Sterilization Consent Fonm - Information for Men	PUB-020
Sterilization Consent Fomi - Infonmation for Women	PUB-019
Targeted Case Management Contact Monitoring Form	DMS-690
Upper-Limb Prosthetic Evaluation	DMS-648
Upper-Limb Prosthetic Prescription	DMS-649
Vendor Performance Report	VendorDerformreDort
Verification of Medical Services	DMS-2618

In order by form number:

AAS-9502	DMS'2633	DIVIS-618	DMS-673	DMS-846
AAS-9506	DMS-2634	Spanish	DMS-679	DMS-873
AAS-9559	DMS-2647	DMS-619	DMS-679A	ECSE-R
Address	DMS-2685	DMS-628	DIVIS-683	HP-0288
Chanqe	DMS-2687	DIVIS-630	DMS-686	HP-AR-004
Autode posit	DMS'2692	DMS-632	DIVIS-689	HP-C1-003
CMS-485	DMS-2698	DMS-633	DMS-ego	HP-CR-002
CSPC-EPSDT	DMS-2704	DMS-635	DMS-693	HP-MFR-001
DCO-645	DMS-32-A	DMS-638	DMS-699	HP-MS-005
DDS/FS#0001.a	DMS-32-0	DMS-640	DMS-699A	MAP-8
DMS-0101	DMS-6	DMS-647	DMS-7708	Performance
OMS-0688	DMS-601	DiVIS-648	DMS-7736	Report
DMS-102	DMS-602	DMS-649	DMS-7782	Provider
DMS-201	DMS-612	DMS-650	DMS-7783	Enrollment Application
DMS-202	DMS-615	DMS-651	DMS-801	and Contract
DMS-2606	Enalish	DMS-652	DMS-802	Packaqe
DMS-2608	DMS-615	DiV1S-652-A	DMS-831	PUB-019
DMS-2609	Spanish	DMS-653	DMS-840	PUB-020
OMS-2610	OMS-616	DMS-664	DMS-841
DMS-2615	DIVIS-618 Enqlish	DMS-671	DMS-844
DMS-2618	DIVIS-618 Enqlish	DWIS-675	DMS-845

Arkansas Medicaid Contacts and Links Click the link to view the infonmation.

American Hospital Association

Americans with Disabilities Act Coordinator

Arkansas Department of Education. Health and Nursing Services Specialist

Arkansas Department of Education. Special Education

Arkansas Department of Finance Administration. Sales and Tax Use Unit

Arkansas Department of Human Services. Division of Aging and Adult Services

Arkansas Department of Human Services. Appeals and Hearings Section

Arkansas Department of Human Services. Division of Behavioral Health Services

Arkansas Department of Human Services. Division of Child Care and Earlv Childhood Education. Child Care Licensing Unit

Arkansas Department of Human Services. Division of Children and Family Services. Contracts IVIanaqement Unit

Arltansas Department of Human Services. Cfiildren's Services

Arkansas Department of Human Services. Division of County Operations. Customer Assistance Section

Arkansas Department of Human Services. Division of Medical Services

Arkansas DHS. Division of IWedical Services Director

Arkansas DHS. Division of Medical Services. Benefit Extension Requests. UR Section

Arkansas DHS. Division of Medical Services. Dental Care Unit

Arkansas DHS. Division of Medical Services. DXC TecJinology Provider Enrollment Unit

Arkansas DHS. Division of Medical Services. Financial Activities Unit

Arkansas DHS. Division of Medical Services. Hearing Aid Consultant

Arkansas DHS. Division of Medical Services. Medical Assistance Unit

Arkansas DHS. Division of Medical Services. Medical Director for Clinical Affairs

Arkansas DHS. Division of Medical Services. Pharmacy Unit

Arkansas DHS. Division of Medical Services. Program Communications Unit

Arkansas DHS. Division of Medical Services. Provider Reimbursement Unit

Arkansas DHS. Division of Medical Services. Third-Party Liability Unit

Arkansas DHS. Division of Medical Services. UR/Home Health Extensions

Arkansas DHS. Division of Medical Services. Utilization Review Section

Arkansas DHS. Division of Medical Services. Visual Care Coordinator

Arkansas Department of Health

Arkansas Department of Health. Health Facility Services

Arkansas Department of Human Services. Accounts Receivable

Arkansas Foundation for Medical Care

Arkansas Foundation for Medical Care. Retrospective Review for Therapy and Prior Authorization for Personal Care for Under Age 21

Arkansas Foundation for Medical Care. Provider Relations Representative

Arkansas Hospital Association

Arkansas Office of Medicaid Inspector General fOMIG)

ARKcds First-B

ARKids First-B ID Card Example

Beacon Health Options (Formerly ValueOptionst

Central Child Health Services Office fEPSDT)

ConnectCare Helpline

County Codes

Dental Contractor

DXC Technology Claims Department

DXC Technology EDI Support Center (formerly AEVCS Help Desk)

DXC Technology InguJrv Unit

DXC Technology Manual Order

DXC Technology Provider Assistance Center fPAC)

DXC Technology Supplied Forms

Example of Beneficiary Notification of Denied ARKids First-B Claim

Example of Beneficiary Notification of Denied Medicaid Claim

First Connections Infant & Toddler Program. Developmental Disabilities Seryices

First Connections Infant & Toddler Program. Developmental Disabilities Services. Appeals

Flow Chart of Intake and Prior Authorization Process For Intervention/Treatment

Health Care Declarations

Immunizations Registry Help Desk

Magellan Pharmacy Call Center

Medicaid ID Card Example

Medicaid Managed Care Services fMMCS)

Medicaid Reimbursement Unit Communications Hotline

Medicaid Tooth Numbering System

National Supplier Clearinghouse

Partners Provider Certification

Primary Care Physician fPCP) Enrollment Voice Response System

Provider Qualifications. Division of Behavioral Health Services

Select Optical

Standard Register

Table of Desirable Weights

U.S. Government Printing Office

Vendor Performance Report

Provider Address/Email Change Form

Click here to view image

Authorization for Electronic Funds Transfer (Automatic Deposit)

Dear Provider:

Effective November 1, 2017, Provider Enrollment will no longer accept provider enrollment applications without a completed authorization for Electronic Funds Transfer (EFT).Providers must utilize EFT, which allows your Medicaid payments to be directly deposited into your bank account. In addition to providing more secure payment and decreased administrative costs, you will notice a difference in your cash flow with EFT because it makes your money available sooner than the actual clearance date of paper checks. Additionally, please verify that your Remittance Advice is set to electronic delivery. Arkansas IVIedicaid appreciates your cooperation in allowing us to become more efficient and more environmentally friendly.

When enrolling as a Medicaid provider, you must complete the Authorization for Electronic Funds Transfer forni and'attach a VOIDED CHECK OR A LETTER FROM THE BANK REFLECTING THE BANK'S ABA NUMBER AND YOUR ACCOUNT NUMBER to have vour Medicaid payment automatically deposited.

If you have any further questions concerning this letter, please contact the Provider Assistance Center at 501-376-2211 (local or out-of-state) or 1-800-457 -4454 (in-state WATS).

Sincerely,

Arkansas Department of Human Services

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Arkansas Administrative CodeAgency 016 - DEPARTMENT OF HUMAN SERVICESDivision 06 - Medical ServicesRule 016.06.17-022 - SecIII-1-17; SecI-2-17; SecV-3-17

Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.17-022 - SecIII-1-17; SecI-2-17; SecV-3-17