016.06.17 Ark. Code R. 022
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:
Each provider must notify the Medicaid Provider Enrollment Unit in writing immediately regarding any changes to its application or contract status, such as:
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.
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.
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 | 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
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
016.06.17 Ark. Code R. 022