016.06.12 Ark. Code R. 009
The purpose of the Autism waiver is to provide one-on-one, intensive early intervention treatment for young children ages eighteen (18) months through six (6) years with a diagnosis of autism. The waiver participants must meet the ICF/MR level of care and have a diagnosis of autism.
The community-based services offered through the Autism waiver are as follows:
The waiver program is operated by the University of Arkansas for Medical Sciences (UAMS) Partners under the administrative authority of the Division of Medical Services.
ConnectCare is the Arkansas Medicaid Primary Care Case Management (PCCM) system. In ConnectCare, a Medicaid beneficiary selects and enrolls with a primary care physician (PCP) that has contracted with DMS to be responsible for managing the health care of a limited number (specified by the PCP) of Medicaid enrollees.
A PCP contracts with DMS to provide primary care, health education and case management for his or her enrollees. DMS pays the PCP a monthly per-enrollee case management fee in addition to the regular Medicaid fee-for-service reimbursement.
The PCP is responsible for referring enrollees to specialists and other providers; therefore, he or she is responsible for deciding whether a particular referral is medically necessary. A PCP may make such decisions in consultation with physicians or other professionals as needed and in accordance with his or her medical training and experience; however, a PCP is not required to make any referral simply because it is requested.
A PCP coordinates his or her enrollees' medical and rehabilitative services with the providers of those services. Medical and rehabilitative professionals to whom a PCP refers a patient are required to report to or consult with the PCP so that the PCP can coordinate care and monitor an enrollee's status, progress and outcomes.
Most Medicaid beneficiaries, and children participating in ARKids First-B, must enroll with a PCP to receive covered services. Some individuals are not required to enroll with a PCP. Few services are covered without PCP referral. See Sections 170.000 through 173.000 for details regarding ConnectCare.
The Developmental Disability Services Alternative Community Services (DDS ACS) waiver program is for beneficiaries who, without the waiver's services, would require institutionalization. Participants must not be residents of a hospital, nursing facility or intermediate care facility for the mentally retarded (ICF/MR).
DDS ACS eligibility requires a determination of categorical eligibility, a determination of level of care, the development of a plan of care and a cost comparison to determine the cost- effectiveness of the plan of care. The DDS ACS program further requires advising the beneficiary that he or she may freely choose between waiver and institutional services.
Services supplied through this program are:
Detailed information may be found in the DDS ACS Waiver provider manual.
ElderChoices is designed for beneficiaries aged 65 and older, who, without the waiver's services, would require an intermediate level of care in a nursing home. The services listed below are designed to maintain beneficiaries at home and preclude or postpone institutionalization.
Elder Choices eligibility requires a determination of categorical eligibility, a determination of level of care, the development of a plan of care and a cost comparison to determine the cost-effectiveness of the plan of care. ElderChoices requires notifying the beneficiary that he or she may freely choose between waiver services and institutional services.
Refer to the ElderChoices provider manual for more detailed information.
SUBJECT: Provider Manual Update Transmittal SecV-2-12
Claim Forms
Red-ink Claim 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- HP-MC-001 | 1-800-457-4454 |
Long 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 (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 -AAS-9559 | Client Employer |
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 | HP-MS-005 |
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 |
Research Request Form | HP-0288 |
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 |
Chanqe |
Autodeposit |
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 |
Enqlish |
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-0288 |
HP-AR-004 |
HP-CI-003 |
HP-CR-002 |
HP-MFR-001 |
HP-MS-005 |
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
UAMS Partners Provider Certification
U.S. Government Printing Office
ValueOptions
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 |
* NOTE: IF THE TAX FORM IS NOT ATTACHED THE APPLICATION WILL BE DENIED
016.06.12 Ark. Code R. 009