016.06.11 Ark. Code R. 008
If a school district or an education service cooperative (ESC) contracts with an individual qualified audiologist, the participation criteria for group providers of audiology services apply. (Refer to Section 202.100.)
If a school district or ESC employs a qualified audiologist, the following participation criteria apply:
The Utilization Review Section of the Division of Medical Services is responsible for authorizing hearing aid services for eligible Medicaid beneficiaries under age 21. Services are provided as a result of a referral from the beneficiary's primary care physician (PCP). If the beneficiary is exempt from the PCP process, then the attending physician must make the referral. Licensed audiologists may provide vestibular testing, aural rehabilitation and aural habilitation services.
A school district or education service cooperative (ESC) may provide audiology services in accordance with a student's Individual Education Program (IEP). A PCP referral is required each time a new IEP is written for the student. When the student is exempt from PCP referral requirements, the student's attending physician must make the referral for audiology services. The referral can encompass the 9-month school year unless the PCP or attending physician specifies otherwise. The school district or ESC must use a Referral Form for Audiology Services - School-Based Setting (form DMS-7783) to obtain the referral and must maintain the completed referral form in the student's medical record. (View or print form DMS-7783.)Certain procedure codes are not payable to school districts and education service cooperatives. (Refer to Sections 242.100 and 242.110 of this manual for more information about non-payable codes.)
Prior to providing hearing aid services to an eligible Medicaid beneficiary, a medical clearance must be obtained from a physician. This clearance must indicate if there are any medical or surgical indications contrary to fitting the beneficiary with a hearing aid. An audiological exam must be made by a certified audiologist or a physician. Arkansas Medicaid will not reimburse for a hearing test performed by a State-licensed hearing aid dispenser unless the hearing aid dispenser is also a licensed physician or licensed audiologist. The hearing evaluation must include the audiologist's or physician's recommendations regarding the brand name and model of the hearing aid to be dispensed and the name of the Medicaid dealer the patient has chosen to provide the hearing aid. The cost of the hearing aid should be provided if available. The medical clearance and hearing evaluation and a copy of the audiogram must be forwarded to the Division of Medical Services Utilization Review (UR) Section and must reach the UR Section within 6 months from the date the above evaluations were performed. View or print the Division of Medical Services Utilization Review Section contact information. After reviewing the medical clearance from the physician and the audiological evaluation from the audiologist or the physician, a letter of authorization is sent from the Utilization Review Section to the Medicaid provider dispensing the hearing aid.
Fitting and servicing the hearing aid is performed by a licensed dispenser. The dealer must submit his or her claim for payment to HP Enterprise Services with the charges and serial numbers of the aid dispensed. Please refer to Section 240.000 of this manual for billing instructions and procedure codes regarding hearing aids.
The beneficiary is entitled to three follow-up visits to the dealer who dispensed the aid for the purpose of learning proper operation and care of the aid. The Medicaid Program does not reimburse the provider an additional amount for these three visits.
There is a one-year warranty period during which all necessary adjustments, parts and replacements to the transmitter and receiver are provided at no cost to the beneficiary or to the Medicaid Program. At the expiration of the warranty period, the dealer will be reimbursed at the lesser of 75% of charges billed to private patients or the Title XIX maximum charge allowed for necessary repairs and replacements.
Repairs and replacements to the transmitter or receiver of hearing aids not purchased through the Medicaid Program may be authorized in the same manner as aids purchased through the Program. Medicaid will make no reimbursement for this equipment during the one-year warranty period.
Replacements are not covered under the Medicaid Program one-year warranty period. Reimbursement is made by Medicaid at 68% of charges billed to private pay patients.
In cases of equipment abuse, no payment will be made by the Medicaid Program. The beneficiary (or parent or guardian) is encouraged to purchase hearing aid insurance from the dealer to cover the cost of repairs or replacements.
The Arkansas Medicaid Program does not cover assistive listening devices that are prescribed solely for social or educational development.
Use the following procedure codes for audiological function tests.
CPT Codes | |||||||
92506 | 92507 | 92508 | 92540f | 92541f | 92542f | 92543f | 92544f |
92545f | 92550 | 92551 | 92552 | 92553 | 92555 | 92556 | 92557 |
92559 | 92560f | 92561f | 92562f | 92563f | 92564f | 92565 | 92567 |
92568 | 92569 | 92570 | 92571 | 92572 | 92573 | 92575 | 92576 |
92577 | 92579 | 92582 | 92583 | 92584f | 92585 | 92586 | 92587 |
92588 | 92590 | 92591 | 92594 | 92595 | 92626 | 92627 | 92630 |
92633 | 92700f | ||||||
Jse the following procedure code for hearing screenings for beneficiaries underage 21 in the)hild Health Services (EPSDT) Program.
HCPCS Procedure Code | Modifier |
V5008 | EP |
Use the following procedure codes for hearing aid equipment for beneficiaries under age 21 in the Child Health Services (EPSDT) Program. Medicaid covers up to 2 hearing aids per beneficiary each six-months. Hearing aid procedure codes may be billed electronically or on a paper claim form.
HCPCS Procedure Codes | |||||||
V5014*f | V5030f | V5040f | V5050f | V5060f | V5120f | V5130f | V5140f |
V5170f | V5180f | V5210f | V522f0 | V5267**| | V5299f | ||
*Repairs require prior authorization
"Accessories
f Non-payable to a school district or ESC
Electronic and paper claims require the same National Place of Service Code.
Place of Service | Place of Service Codes |
Inpatient Hospital | 21 |
Doctor's Office | 11 |
Ambulatory Surgical Center | 24 |
Public School | 03 |
Field Name and Number | Instructions for Completion | |
1. | (type of coverage) | Not required. |
1a. | INSURED'S I.D. NUMBER (For Program in Item 1) | Beneficiary's or participant's 10-digit Medicaid or ARKids First-A or ARKids First-B identification number. |
2. | PATIENT'S NAME (Last Name, First Name, Middle Initial) | Beneficiary's or participant's last name and first name. |
3. | PATIENT'S BIRTH DATE | Beneficiary's or participant's date of birth as given on the individual's Medicaid or ARKids First-A or ARKids First-B identification card. Format: MM/DD/YY. |
SEX | Check M for male or F for female. | |
4. | INSURED'S NAME (Last Name, First Name, Middle Initial) | Required if insurance affects this claim. Insured's last name, first name, and middle initial. |
5. | PATIENT'S ADDRESS (No., Street) | Optional. Beneficiary's or participant's complete mailing address (street address or post office box). |
CITY | Name of the city in which the beneficiary or participant resides. | |
STATE | Two-letter postal code for the state in which the beneficiary or participant resides. | |
ZIP CODE | Five-digit zip code; nine digits for post office box. | |
TELEPHONE (Include Area Code) | The beneficiary's or participant's telephone number or the number of a reliable message/contact/ emergency telephone. | |
6. | PATIENT RELATIONSHIP TO INSURED | If insurance affects this claim, check the box indicating the patient's relationship to the insured. |
7. | INSURED'S ADDRESS (No., Street) CITY STATE ZIP CODE TELEPHONE (Include Area Code) | Required if insured's address is different from the patient's address. |
8. | PATIENT STATUS | Not required. |
9. | OTHER INSURED'S NAME (Last name, First Name, Middle Initial) | If patient has other insurance coverage as indicated in Field 11 d, the other insured's last name, first name, and middle initial. |
a. OTHER INSURED'S POLICY OR GROUP NUMBER | Policy and/or group number of the insured individual. | |
b. OTHER INSURED'S DATE OF BIRTH | Not required. | |
SEX | Not required. | |
c. EMPLOYER'S NAME OR SCHOOL NAME | Required when items 9 a-d are required. Name of the insured individual's employer and/or school. | |
d. INSURANCE PLAN NAME OR PROGRAM NAME | Name of the insurance company. | |
10. | IS PATIENT'S CONDITION RELATED TO: | |
a. EMPLOYMENT? (Current or Previous) | Check YES or NO. | |
b. AUTO ACCIDENT? | Required when an auto accident is related to the services. Check YES or NO. | |
PLACE (State) | If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place. | |
c. OTHER ACCIDENT? | Required when an accident other than automobile is related to the services. Check YES or NO. | |
10d. RESERVED FOR LOCAL USE | Not used. | |
11. | INSURED'S POLICY GROUP OR FECA NUMBER | Not required when Medicaid is the only payer. |
a. INSURED'S DATE OF BIRTH | Not required. | |
SEX | Not required. | |
b. EMPLOYER'S NAME OR SCHOOL NAME | Not required. | |
c. INSURANCE PLAN NAME OR PROGRAM NAME | Not required. | |
d. IS THERE ANOTHER HEALTH BENEFIT PLAN? | When private or other insurance may or will cover any of the services, check YES and complete items 9a through 9d. | |
12. | PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE | Not required. |
13. | INSURED'S OR AUTHORIZED PERSON'S SIGNATURE | Not required. |
14. | DATE OF CURRENT: | Required when services furnished are related to an |
ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP) | accident, whether the accident is recent or in the past. Date of the accident. | |
15. | IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE FIRST DATE | Not required. |
16. | DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION | Not required. |
17. | NAME OF REFERRING PROVIDER OR OTHER SOURCE | Primary Care Physician (PCP) referral is required for Hearing Services. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title. |
17a. | . (blank) | The 9-digit Arkansas Medicaid provider ID number of the referring physician. |
17b. | . NPI | Not required. |
18. | HOSPITALIZATION DATES RELATED TO CURRENT SERVICES | When the serving/billing provider's services charged on this claim are related to a beneficiary's or participant's inpatient hospitalization, enter the individual's admission and discharge dates. Format: MM/DD/YY. |
19. | RESERVED FOR LOCAL USE | Schools, school districts and education service cooperatives must enter the LEA number of the facility or district providing the service. |
20. | OUTSIDE LAB? | Not required. |
$ CHARGES | Not required. | |
21. | DIAGNOSIS OR NATURE OF ILLNESS OR INJURY | Diagnosis code for the primary medical condition for which services are being billed. Up to three additional diagnosis codes can be listed in this field for information or documentation purposes. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) diagnosis coding current as of the date of service. |
22. | MEDICAID RESUBMISSION CODE | Reserved for future use. |
ORIGINAL REF. NO. | Reserved for future use. | |
23. | PRIOR AUTHORIZATION NUMBER | The prior authorization or benefit extension control number if applicable. |
24A. | DATE(S) OF SERVICE | The "from" and "to" dates of service for each billed service. Format: MM/DD/YY. 1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month. 2. Providers may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of the service on each day of the date sequence. |
B. PLACE OF SERVICE | Two-digit national standard place of service code. See Section 242.200 for codes. | |
C. EMG D. PROCEDURES, SERVICES, OR SUPPLIES | Not required. | |
CPT/HCPCS | Enter the correct CPT or HCPCS procedure code from Sections 242.100 through 242.110. | |
MODIFIER | Modifier(s) if applicable. | |
E. DIAGNOSIS POINTER | Enter in each detail the single number-1, 2, 3, or 4-that corresponds to a diagnosis code in Item 21 (numbered 1,2,3, or 4) and that supports most definitively the medical necessity of the service(s) identified and charged in that detail. Enter only one number in E of each detail. Each DIAGNOSIS POINTER number must be only a 1, 2, 3, or 4, and it must be the only character in that field. | |
F. $ CHARGES | The full charge for the service(s) totaled in the detail. This charge must be the usual charge to any client, patient, or other recipient of the provider's services. | |
G. DAYS OR UNITS | The units (in whole numbers) of service(s) provided during the period indicated in Field 24A of the detail. | |
H. EPSDT/Family Plan | Enter E if the services resulted from a Child Health Services (EPSDT) screening/referral. | |
I. IDQUAL | Not required. | |
J. RENDERING PROV IDER ID# | The 9-digit Arkansas Medicaid provider ID number of the individual who furnished the services billed for in the detail. | |
NPI | Not required. | |
25. | FEDERAL TAX I.D. NUMBER | Not required. This information is carried in the provider's Medicaid file. If it changes, please contact Provider Enrollment. |
26. | PATIENT'S ACCOUNT NO. | Optional entry that may be used for accounting purposes; use up to 16 numeric or alphabetic characters. This number appears on the Remittance Advice as "MRN." |
27. | ACCEPT ASSIGNMENT? | Not required. Assignment is automatically accepted by the provider when billing Medicaid. |
28. | TOTAL CHARGE | Total of Column 24F-the sum all charges on the claim. |
29. | AMOUNT PAID | Enter the total of payments previously received on this claim. Do not include amounts previously paid by Medicaid. *Do not include in this total the automatically deducted Medicaid or ARKids First-B co-payments. |
30. | BALANCE DUE | From the total charge, subtract amounts received from other sources and enter the result. |
31. | SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS | The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider's direction. "Provider's signature" is defined as the provider's actual signature, a rubber stamp of the provider's signature, an automated signature, a typewritten signature, or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable. |
32. | SERVICE FACILITY LOCATION INFORMATION | If other than home or office, enter the name and street, city, state, and zip code of the facility where services were performed. |
a. (blank) | Not required. | |
b. (blank) | Not required. | |
33. | BILLING PROVIDER INFO & PH# | Billing provider's name and complete address. Telephone number is requested but not required. |
a. (blank) | Not required. | |
b. (blank) | Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider. | |
Provider Manual Update Transmittal #SecV-3-11Section
V SECTION V - FORMS
Claim Forms
Red-inklaim Forms
The following is a list of the red-ink claim forms required by Arkansas Medicaid. The forms below cannot be printed from this manual for use. Information about where to get the forms and links to samples of the forms is available below. To view a sample form, click the form name.
Claim Type | Where To Get Them |
Professional - CMS-1500 | Business Form Supplier |
Institutional-CMS-1450* | Business Form Supplier |
Visual Care - DMS-26-V | 1-800-457-4454 |
Inpatient Crossover- EDS-MC-001 | 1-800-457-4454 |
Long Term Care Crossover- EDS-MC-002 | 1-800-457-4454 |
Outpatient Crossover- EDS-MC-003 | 1-800-457-4454 |
Professional Crossover - EDS-MC-004 | 1-800-457-4454 |
* For dates of service after 11/30/07 - ALL HOSPICE PROVIDERS USE ONLY FORM CMS-1450 (formerly UB-04) for billing.
Claim Forms
The following is a list of the non-red-ink claim forms required by Arkansas Medicaid. Information about where to get a supply of the forms and links to samples of the forms is available below. To view a sample form, click the form name.
Claim Type | Where To Get Them |
Alternatives Attendant Care Provider Claim Form - | Client Employer |
AAS-9559 | |
Dental - ADA-J400 | Business Form Supplier |
Arkansas Medicaid Forms
The forms 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 Change Form | DMS-673 |
Adjustment Request Form - Medicaid XIX | HP-AR-004 |
AFMC Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components | DMS-679A |
Amplification/Assistive Technology Recommendation Form | DMS-686 |
Application for WebRA Hardship Waiver | DMS-7736 |
Approval/Denial Codes for Inpatient Psychiatric Services | DMS-2687 |
Arkansas Early Intervention Infant & Toddler Program Intake/Referral/Application for Services | DDS/FS#0001.a |
ARKids First Mental Health Services Provider Qualification Form | DMS-612 |
Assisted Living Waiver Plan of Care | AAS-9565 |
Authorization for Automatic Deposit | autodeposit |
Authorization for Payment for Services 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 Information | DMS-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 Services/Items Not Specifically Included in the Medicaid State Plan | DMS-693 |
Early Childhood Special Education Referral Form | ECSE-R |
EPSDT Provider Agreement | DMS-831 |
Evaluation Form Lower-Limb | DMS-646 |
Explanation of Check Refund | HP-CR-002 |
Gait Analysis Full Body | DMS-647 |
Home Health Certification and Plan of Care | CMS-485 |
Hospital/Physician/Certified Nurse Midwife Referral 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 Prescription | DMS-651 |
Media Selection/E-Mail Address Change Form | Medemchanqe |
Medicaid Claim Inquiry Form | HP-CI-003 |
Medicaid Form Request | HP-MFR-001 |
Medical Assistance Dental Disposition | DMS-2635 |
Medical Equipment Request for Prior Authorization & Prescription | DMS-679 |
Medical Transportation and Personal Assistant Verification | DMS-616 |
Mental Health Services 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 | DMS-675 |
Personal Care Assessment and Service Plan | DMS-618 English DMS-618 Spanish |
Practitioner Identification Number Request Form | 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 |
Prior Authorization (PA) Request for Extension of Benefits-Prescription Drugs | DMS-0685-14 |
Procedure Code/NDC Detail Attachment Form | DMS-664 |
Prosthetic-Orthotic Lower-Limb Amputee Evaluation | DMS-650 |
Prosthetic-Orthotic Upper-Limb Amputee Evaluation | DMS-648 |
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 | AppMaterial |
Referral for Audiology Services - School-Based Setting | DMS-7783 |
Referral for Certification of Need Medicaid Inpatient Psychiatric Services for Under Age 21 | DMS-2634 |
Referral for Medical Assistance | DMS-630 |
Request for Appeal | DMS-840 |
Request for Extension of Benefits | DMS-699 |
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 Orthodontic Treatment | DMS-32-0 |
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 |
Service Log - Personal Care Delivery and Aides Notes | DMS-873 |
Sterilization Consent Form | DMS-615 English DMS-615 Spanish |
Sterilization Consent Form - Information for Men | PUB-020 |
Sterilization Consent Form- Information for Women | PUB-019 |
Upper-Limb Prosthetic Prescription | DMS-649 |
Vendor Performance Report | Vendorperformreport |
Verification of Medical Services | DMS-2618 |
In order by form number:
AAS-9502 |
AAS-9559 |
AAS-9565 |
Address |
Change |
Autode posit |
CMS-485 |
CSPC-EPSDT |
DCO-645 |
DDS/FS#0001.a |
DMS-0101 |
DMS-0685-14 |
DMS-0688 |
DMS-102 |
DMS-201 |
DMS-202 |
DMS-2606 |
DMS-2608 |
DMS-2609 |
DMS-2610 |
DMS-2615 |
DMS-2618 |
DMS-2633 |
DMS-2634 |
DMS-2635 |
DMS-2647 |
DMS-2685 |
DMS-2687 |
DMS-2692 |
DMS-2698 |
DMS-32-A |
DMS-32-0 |
DMS-601 |
DMS-602 |
DMS-612 |
DMS-615 |
Enqlish |
DMS-615 |
Spanish |
DMS-616 |
DMS-618 |
English |
DMS-618 |
Spanish |
DMS-619 |
DMS-628 |
DMS-630 |
DMS-632 |
DMS-633 |
DMS-635 |
DMS-638 |
DMS-640 |
DMS-646 |
DMS-647 |
DMS-648 |
DMS-649 |
DMS-650 |
DMS-651 |
DMS-652 |
DMS-652-A |
DMS-653 |
DMS-664 |
DMS-671 |
DMS-675 |
DMS-673 |
DMS-679 |
DMS-679A |
DMS-683 |
DMS-686 |
DMS-689 |
DMS-693 |
DMS-699 |
DMS-699A |
DMS-7708 |
DMS-7736 |
DMS-7782 |
DMS-7783 |
DMS-831 |
DMS-840 |
DMS-873 |
ECSE-R |
HP-AR-004 |
HP-CI-003 |
HP-CR-002 |
HP-MFR-001 |
MAP-8 |
Performance |
Report |
Provider |
Enrollment |
Application |
and Contract |
Packaqe |
PUB-019 |
PUB-020 |
Arkansas Medicaid Contacts and Links
Click the link to view the information.
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 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 Early Childhood Education, Child Care Licensing Unit
Arkansas Department of Human Services, Division of Children and Family Services, Contracts Management Unit
Arkansas Department of Human Services, Children'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 Medical 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, HP Enterprise Services 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
Arkansas DHS, Division of Medical Services, Pharmacy Unit
Arkansas DHS, Division of Medical Services, Program Communications Unit
Arkansas DHS, Division of Medical Services, Program Integrity Unit (PI)
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 Hospital Association
ARKids First-B
ARKids First-B ID Card Example
Central Child Health Services Office (EPSDT)
ConnectCare Helpline
County Codes
CPT Ordering
Dental Contractor
HP Enterprise Services Claims Department
HP Enterprise Services EDI Support Center (formerly AEVCS Help Desk)
HP Enterprise Services Inquiry Unit
HP Enterprise Services Manual Order
HP Enterprise Services Pharmacy Help Desk
HP Enterprise Services Provider Assistance Center (PAC)
HP Enterprise Services 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 Services
Flow Chart of Intake and Prior Authorization Process For Intervention/Treatment
Health Care Declarations
ICD-9-CM, CPT, and HCPCS Reference Book Ordering
Immunizations Registry Help Desk
Medicaid ID Card Example
Medicaid Managed Care Services (MMCS)
Medicaid Reimbursement Unit Communications Hotline
Medicaid Tooth Numbering System
National Supplier Clearinghouse
Primary Care Physician (PCP) Enrollment Voice Response System
Provider Qualifications, Division of Behavioral Health Services
QSource of Arkansas
Select Optical
Standard Register
Table of Desirable Weights
ValueOptions
U.S. Government Printing Office
Vendor Performance Report
DIVISION OF MEDICAL SERVICES
MEDICAL ASSISTANCE PROGRAM
PROVIDER APPLICATION
As a condition for entering into or renewing a provider agreement, all applicants must complete this provider application. A true, accurate and complete disclosure of all requested information is required by the Federal and State Regulations that govern the Medical Assistance Program. Failure of an applicant to submit the requested information or the submission of inaccurate or incomplete information may result in refusal by the Medical Assistance program to enter into, renew or continue a provider agreement with the applicant. Furthermore, the applicant is required by Federal and State Regulations to update the information submitted on the Provider Application.
Whenever changes in this information occur, please submit the change in writing to:
Medicaid Provider Enrollment Unit
HP Enterprise Services
P.O. Box 8105
Little Rock, AR 72203-8105
All dates, except where otherwise specified, should be written in the month/day/year (MMDDYY) format. Please print all information.
This information is divided into sections. The following describes which sections are to be completed by the applicant:
Section I | All providers |
Section II | Facilities Only |
Section III | Pharmacists/Registered Respiratory Therapist Only |
Section IV | Provider Group Affiliations |
Electronic Fund Transfer | All Providers (optional) |
Managed Care Agreement | Primary Care Physician |
W-9 Tax Form | All Providers |
Contract | All Providers |
Ownership and Conviction | |
Disclosure | All Providers |
Disclosure of Significant | |
Business Transactions | All Providers |
016.06.11 Ark. Code R. 008