Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.13-005 - State Plan 2012-003 & Provider Manual Update Transmittal Sections I-7-12 & V-11-12

Current through Register Vol. 49, No. 6, June, 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 type 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 form 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
				(Application Packet).
In addition to the submission of the Application Packet, the
				following forms 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 PCP
			 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 form is applicable for
			 individual providers who choose to authorize a group to bill and receive
			 reimbursement on their behalf.
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.
			 Electronic Funds Transfer (EFT) Authorization for 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 Change Form (DMS-673)
			 (
View or print form DMS-673 - Address Change
			 Form.
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.