Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.10-012 - Sections I, IV and V of all Medicaid Provider Manuals

Current through Register Vol. 49, No. 6, June, 2024
Section I
141.000
Provider Enrollment
			 10-8-10
Any provider of health care services
must
be enrolled in the Arkansas Medicaid Program
				before Medicaid will cover any services provided to Arkansas Medicaid
				beneficiaries. Enrollment as a new Medicaid provider is conditioned upon
				approval of a completed provider enrollment and contract package (AppMaterial),
				application and the execution of a Medicaid Provider contract. 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.
The provider enrollment functions for the 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. New providers must complete all appropriate portions of a
				provider enrollment and contract package (AppMaterial) and submit a copy of all
				certifications and licenses verifying compliance with enrollment criteria for
				the discipline to be practiced. 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
				(AppMaterial).
A potential provider may complete the necessary forms for
				enrollment and submit them via the Internet by connecting to the Arkansas
				Medicaid Web site at www.medicaid.state.ar.us/or they may return the printed
				forms to the Medicaid Provider Enrollment Unit.
View or print
				the Medicaid Provider Enrollment Unit contact
				information.
In addition to the information in Section 140.000, Section II
				of each program's provider manual contains provider type-specific participation
				requirements and program guidelines where applicable.
All providers must sign an 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.
Upon receipt and approval of the provider application, required
				documentation and a Medicaid contract, 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. Provider eligibility is
				retroactive one year from the date the provider agreement is approved, the
				effective date of the provider's license or certification or the date Medicaid
				implemented the provider's program or whichever date is the most recent.
Instructions for billing and specific details concerning the
				Arkansas Medicaid Program are contained within this manual. Providers must read
				aH sections of the manual
before
signing
				the contract. The manual is incorporated by reference into the Medicaid
				contract and providers must comply with its terms and conditions in order to
				participate in the Arkansas Medicaid Program.
142.100
General Conditions
10-8-10
A. Each provider must be
			 licensed, certified or both, as required by law, to furnish all goods or
			 services that may be reimbursed by the Arkansas Medicaid Program.
B. Providers must adhere to all applicable
			 standards for professional conduct and quality care.
C. It is the responsibility of each provider
			 to read the complete Arkansas Medicaid provider manual provided by DMS and to
			 abide by the rules and regulations specified in the manual.
D. All services provided must be medically
			 necessary. The beneficiary is not liable for a claim or portion of a claim when
			 the Medicaid Program, either directly or through a designee, determines that
			 the services were not medically necessary.
E. Services will be provided to qualified
			 beneficiaries without regard to race, color, national origin or disability
			 within the provisions of Title VI of the Federal Civil Rights Act, Section 504
			 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of
			 1990.
F. Each provider must notify
			 the Medicaid Provider Enrollment Unit in writing immediately regarding any
			 changes to its application or contract, such as:
1. Change of address
(View
			 or print form DMS-673 - Address Change Form.)
2. Change in members of group, professional
			 association or affiliations*
3.
			 Change in practice or specialty*
4.
			 Change in Federal Employer Identification Number (FEIN)*
5. Retirement or death of provider*
6. Complete change of ownership
(View or print form DMS-0688 - Provider Change of Ownership
			 Information Form.)
7. Change in Ownership Control (5% or more)
			 or Conviction of Crime
(View or print form DMS-675 -
			 Ownership and Conviction Disclosure.)
8. Disclosure of Significant Business
			 Transactions
(View or print form DMS-689 -Disclosure of
			 Significant Business Transactions
.)
Changes in items two (2) through five (5) above may be properly
				addressed through a letter of explanation with the provider's original
				signature or an approved electronic signature and the appropriately corrected
				pages of the provider application document
(View or print
				form DMS-652 - Provider Application Form)
.
G. Except for Medicaid-covered
			 services and other professional services furnished in exchange for the
			 provider's usual and customary charges, a Medicaid provider may not knowingly
			 give, offer, furnish, provide or transfer money, services or any thing of value
			 for less than fair market value to any Medicaid beneficiary, to anyone related
			 to any Medicaid beneficiary within the third degree or any person residing in
			 the household of a beneficiary.
This rule does not apply to:
1. Pharmaceutical samples provided to a
			 physician at no cost or to other comparable circumstances where the provider
			 obtains the sample at no cost and distributes the samples without regard to
			 Medicaid eligibility.
2. Provider
			 actions taken under the express authority of state or federal Medicaid laws or
			 rules or the provider's agreement to participate in the Medicaid
			 Program.
171.210
ConnectCare Caseload Maximum
			 and PCP Caseload Limits
10-8-10
A.
			 Each PCP may establish an upper limit to his or her Medicaid caseload, up to
			 the default maximum of 2500.
1. The state may
			 permit higher maximum caseloads in areas the federal government has designated
			 as medically underserved.
2. The
			 state may permit higher maximum caseloads for PCPs who state in writing that
			 the default maximum will create a hardship for them, their patients and/or the
			 community they serve.
B.
			 The state will not require any PCP to accept a caseload greater than the PCP's
			 requested caseload maximum.
C. At
			 any time, a PCP may increase or decrease his or her maximum desired caseload by
			 any amount, up to the default maximum by submitting a signed request to his or
			 her Provider Relations Representative, or on-line through the Medicaid Website
(
www.medicaid.state.ar.us/
)
,
			 Provider Enrollment Information, and Access to the Provider Information
			 Portal.
D. To request an increase
			 in a PCP caseload above the default maximum, the PCP must submit a written
			 request to the Provider Relations Representative.
View or
			 print Provider Relations Representative contact
			 information.
E.
			 Prior to making the request for an increase of a caseload that is already at
			 the default maximum, PCPs are encouraged to review their caseload for inactive
			 patients to determine if those patients should be removed from their caseload.
			 To do so, PCPs may use the Arkansas Medicaid Information Interchange (AMII) web
			 portal. If it is determined that the inactive patients should be removed from
			 his or her caseload, the PCP must:
1. Contact
			 the patient in writing at least 30 days in advance of the effective date of the
			 termination to give the patient the option of making a visit to the PCP to
			 remain an active patient. If the patient does not choose to make a visit to the
			 PCP, the termination can be effective at the end of 30 calendar days.
2. With approval from his or her Provider
			 Relations Representative, the PCP may add and see new patients during the 30
			 calendar day notification process of inactive patients.
3. The notice must state that the enrollee
			 has 30 calendar days in which to enroll with a different PCP.
4. The PCP must forward a copy of the notice
			 to the enrollee and to the local DHS office in the enrollee's county of
			 residence.
173.200
PCP Selection and Enrollment
			 at PCP Offices and Clinics 10-8-10
Physician and single-entity PCPs may enroll Medicaid
				beneficiaries and ARKids First-B participants by means of the telephonic voice
				response system (VRS.)
A. Enrollees
			 must document their PCP choice on a Primary Care Physician Selection and Change
			 form (DMS 2609 or DCO-2609.)
1. The form must
			 be completed, dated and signed by the enrollee.
2. The enrollee may request and receive a
			 copy of the form.
3. The PCP office
			 must retain a copy of the form in the enrollee's file.
B. Enrolling the beneficiary is performed by
			 accessing the VRS and following the instructions.
View or
			 print Voice Response System (VRS) contact
			 information.
C.
			 When a PCP wants to add a new enrollee but the PCP's Medicaid caseload is full
			 or when a PCP wants to increase or decrease his or her caseload limit:
1. The PCP may increase or decrease his or
			 her maximum desired caseload by any amount, at any time, up to the default
			 maximum by submitting a signed request to their Medicaid Managed Care Services
			 (MMCS) Provider Relations Representative or, on-line through the Medicaid
			 Website www.medicaid.state.ar.us/ Provider Enrollment Information, Access to
			 the Provider Information Portal.
2.
			 Prior to making the request for an increase of a caseload that is already at
			 maximum, the PCP is encouraged to review their caseload using the AMI I
			 (Arkansas Medicaid Information Interchange) web portal for inactive patients,
			 to determine if those patients should be removed from their caseload. An
			 increase in PCP caseload above the default maximum requires a written request
			 to the Provider Relations Representative.
View or print
			 Provider Relations Representative contact information
.
Provider Manual Update Transmittal #SeclV-1-10
Section IV SECTION IV - GLOSSARY
400.000
10-8-10
AAFP
American Academy of Family Physicians
AAP
American Academy of Pediatrics
ABESPA
Arkansas Board of Examiners in Speech-Language
						  Pathology and Audiology
ACD
Augmentative Communication Device
ACIP
Advisory Committee on Immunization
						  Practices
ACES
Arkansas Client Eligibility System
ACS
Alternative Community Services
ADE
Arkansas Department of Education
ADH
Arkansas Department of Health
ADL
Activities of Daily Living
AFDC
Aid to Families with Dependent Children (cash
						  assistance program replaced by the Transitional Employment Assistance (TEA)
						  program)
AFMC
Arkansas Foundation for Medical Care, Inc.
AH EC
Area Health Education Centers
ALF
Assisted Living Facilities
ALS
Advance Life Support
ALTE
Apparent Life Threatening Events
AMA
American Medical Association
APD
Adults with Physical Disabilities
ARS
Arkansas Rehabilitation Services
ASC
Ambulatory Surgical Centers
AS HA
American Speech-Language-Hearing
						  Association
BIPA
Benefits Improvement and Protection Act
BLS
Basic Life Support
CARF
Commission on Accreditation of Rehabilitation
						  Facilities
CCRC
Children's Case Review Committee
CFA
One Counseling and Fiscal Agent
CFR
Code of Federal Regulations
CHMS
Child Health Management Services
CLIA
Clinical Laboratory Improvement Amendments
CME
Continuing Medical Education
CMHC
Community Mental Health Center
CMS
Centers for Medicare and Medicaid Services
COA
Council on Accreditation
CON
Certification of Need
CPT
Physicians' Current Procedural Terminology
CRNA
Certified Registered Nurse Anesthetist
CSHCN
Children with Special Health Care Needs
CSWE
Council on Social Work Education
D&E
Diagnosis and Evaluation
DAAS
Division of Aging and Adult Services
DBS
Division of Blind Services (currently named Division of
						  Services for the Blind)
DCFS
Division of Children and Family Services
DCO
Division of County Operations
DD
Developmentally Disabled
DDS
Developmental Disabilities Services
DDTCS
Developmental Day Treatment Clinic Services
DHS
Department of Human Services
DLS
Daily Living Skills
DME
Durable Medical Equipment
DMHS
Division of Mental Health Services
DMS
Division of Medical Services (Medicaid)
DOS
Date of Service
DRG
Diagnosis Related Group
DRS
Developmental Rehabilitative Services
DSB
Division of Services for the Blind (formerly Division
						  of Blind Services)
DSH
Disproportionate Share Hospital
DURC
Drug Utilization Review Committees
DYS
Division of Youth Services
EAC
Estimated Acquisition Cost
EFT
Electronic Funds Transfer
EIN
Employer Identification Number
EOB
Explanation of Benefits
EOMB
Explanation of Medicaid Benefits. EOMB may also refer
						  to Explanation of Medicare Benefits.
EPSDT
Early and Periodic Screening, Diagnosis and
						  Treatment
ESC
Education Services Cooperative
FEIN
Federal Employee Identification Number
FPL
Federal Poverty Level
FQHC
Federally Qualified Health Center
GME
Graduate Medical Education
GUL
Generic Upper Limit
HCBS
Home and Community Based Services
HCPCS
Healthcare Common Procedure Coding System
HDC
Human Development Center
HHS
The Federal Department of Health and Human
						  Services
HIC Number
Health Insurance Claim Number
HIPAA
Health Insurance Portability and Accountability Act of
						  1996
HMO
Health Maintenance Organization
HP
Hewlett Packard
IADL
Instrumental Activities of Daily Living
ICD-9-CM
International Classification of Diseases, Ninth
						  Edition, Clinical Modification
ICF/MR
Intermediate Care Facility/Mental
						  Retardation
ICN
Internal Control Number
IDEA
Individuals with Disabilities Education Act
IDG
Interdisciplinary Group
IEP
Individualized Educational Program
IFSP
Individualized Family Service Plan
IMD
Institution for Mental Diseases
IPP
Individual Program Plan
IUD
Intrauterine Devices
JCAHO
Joint Commission on Accreditation of Healthcare
						  Organization
LAC
Licensed Associate Counselor
LCSW
Licensed Certified Social Worker
LEA
Local Education Agencies
LMFT
Licensed Marriage and Family Therapist
LMHP
Licensed Mental Health Practitioner
LPC
Licensed Professional Counselor
LPE
Licensed Psychological Examiner
LSPS
Licensed School Psychology Specialist
LTC
Long Term Care
MAC
Maximum Allowable Cost
MAPS
Multi-agency Plan of Services
MART
Medicaid Agency Review Team
MEI
Medicare Economic Index
MMIS
Medicaid Management Information System
MNIL
Medically Needy Income Limit
MPPPP
Medicaid Prudent Pharmaceutical Purchasing
						  Program
MSA
Metropolitan Statistical Area
MUMP
Medicaid Utilization Management Program
NBCOT
National Board for Certification of Occupational
						  Therapy
NCATE
North Central Accreditation for Teacher
						  Education
NDC
National Drug Code
NET
Non-Emergency Transportation Services
NF
Nursing Facility
NPI
National Provider Identifier
OBRA
Omnibus Budget Reconciliation Act
OHCDS
Organized Health Care Delivery System
OTC
Over the Counter
PA
Prior Authorization
PAC
Provider Assistance Center
PCP
Primary Care Physician
PERS
Personal Emergency Response Systems
PES
Provider Electronic Solutions
PHS
Public Health Services
PIM
Provider Information Memorandum
PL
Public Law
POC
Plan of Care
POS
Place of Service
PPS
Prospective Payment System
PRN
Pro Re Nata or "As Needed"
PRO
Professional Review Organization
ProDUR
Prospective Drug Utilization Review
QMB
Qualified Medicare Beneficiary
QMRP
Qualified Mental Retardation Professional
RA
Remittance Advice. Also called Remittance and Status
						  Report
RFP
Request for Proposal
RHC
Rural Health Clinic
RID
Recipient Identification Number
RSPD
Rehabilitative Services for Persons with Physical
						  Disabilities
RSPMI
Rehabilitation Services for Persons with Mental
						  Illness
RSYC
Rehabilitative Services for Youth and
						  Children
RTC
Residential Treatment Centers
RTP
Return to Provider
RTU
Residential Treatment Units
SBMH
School-Based Mental Health Services
SD
Spend Down
SFY
State Fiscal Year
SMB
Special Low Income Qualified Medicare
						  Beneficiaries
SNF
Skilled Nursing Facility
SSA
Social Security Administration
SSI
Supplemental Security Income
SURS
Surveillance and Utilization Review
						  Subsystem
TCM
Targeted Case Management
TEA
Transitional Employment Assistance
TEFRA
Tax Equity and Fiscal Responsibility Act
TOS
Type of Service
TPL
Third Party Liability
UPL
Upper Payment Limit
UR
Utilization Review
VFC
Vaccines for Children
VRS
Voice Response System
Accommodation
A type of hospital room, e.g., private, semiprivate,
						  ward, etc.
Activities of Daily Living (ADL)
Personal tasks that are ordinarily performed on a daily
						  basis and include eating, mobility/transfer, dressing, bathing, toileting and
						  grooming
Adjudicate
To determine whether a claim is to be paid or
						  denied
Adjustments
Transactions to correct claims paid in error or to
						  adjust payments from a retroactive change
Admission
Actual entry and continuous stay of the beneficiary as
						  an inpatient to an institutional facility
Affiliates
Persons having an overt or covert relationship such
						  that any one of them directly or indirectly controls or has the power to
						  control another
Agency
The Division of Medical Services
Aid Category
A designation within SSI or state regulations under
						  which a person may be eligible for public assistance
Aid to Families with Dependent Children
						  (AFDC)
A Medicaid eligibility category
Allowed Amount
The maximum amount Medicaid will pay for a service as
						  billed before applying beneficiary coinsurance or co-pay, previous TPL payment,
						  spend down liability or other deducted charges
American Medical Association (AMA)
National association of physicians
Ancillary Services
Services available to a patient other than room and
						  board. For example: pharmacy, X-ray, lab and central supplies
Arkansas Client Eligibility System (ACES)
A state computer system in which data is entered to
						  update assistance eligibility information and beneficiary files
Arkansas Foundation for Medical Care, Inc.
						  (AFMC)
State professional review organization
Attending Physician
See Performing Physician.
Automated Eligibility Verification Claims Submission
						  (AEVCS)
On-line system for providers to verify eligibility of
						  beneficiaries and submit claims to fiscal agent
Base Charge
A set amount allowed for a participating provider
						  according to specialty
Beneficiary
Person who meets the Medicaid eligibility requirements,
						  receives an ID card and is eligible for Medicaid services (formerly
						  recipient)
Benefits
Services available under the Arkansas Medicaid
						  Program
Billed Amount
The amount billed to Medicaid for a rendered
						  service
Buy-In
A process whereby the state enters into an agreement
						  with the Medicaid/Medicare and the Social Security Administration to obtain
						  Medicare Part B (and part A when needed) for Medicaid beneficiaries who are
						  also eligible for Medicare. The state pays the monthly Medicare premium(s) on
						  behalf of the beneficiary.
Care Plan
See
Plan of Care (POC).
Casehead
An adult responsible for an AFDC or Medicaid
						  child
Categorically Needy
All individuals receiving financial assistance under
						  the state's approved plan under Title 1, IV-A, X, XIV and XVI of the Social
						  Security Act or in need under the state's standards for financial eligibility
						  in such a plan
Centers for Medicare and Medicaid Services
Federal agency that administers federal Medicaid
						  funding
Child Health Services
Arkansas Medicaid's Early and Periodic Screening,
						  Diagnosis and Treatment (EPSDT) Program
Children's Services
A Title V Children with Special Health Care Needs
						  Program administered by the Arkansas Division of Developmental Disabilities
						  Services to provide medical care and service coordination to chronically and
						  disabled children
Claim
A request for payment for services rendered
Claim Detail
See
Line Item.
Clinic
(1) A facility for diagnosis and treatment of
						  outpatients. (2) A group practice in which several physicians work
						  together
Closed-end Provider Agreement
An agreement for a specific period of time not to
						  exceed 12 months, which must be renewed in order for the provider to continue
						  to participate in the Title XIX Program.
Coinsurance
The portion of allowed charges the patient is
						  responsible for under Medicare. This may be covered by other insurance, such as
						  Medi-Pak or Medicaid (if entitled). This also refers to the portion of a
						  Medicaid covered inpatient hospital stay for which the beneficiary is
						  responsible.
Contract
Written agreement between a provider of medical
						  services and the Arkansas Division of Medical Services. A contract must be
						  signed by each provider of services participating in the Medicaid
						  Program.
Co-pay
The portion of the maximum allowable (either that of
						  Medicaid or a third-party payer) that the insured or beneficiary must
						  pay
Cosmetic Surgery
Any surgical procedure directed at improving appearance
						  but not medically necessary
Covered Service
Service which is within the scope of the Arkansas
						  Medicaid Program
Current Procedural Terminology
A listing published annually by AMA consisting of
						  current medical terms and the corresponding procedure codes used for reporting
						  medical services and procedures performed by physicians
Credit Claim
A claim transaction which has a negative effect on a
						  previously processed claim.
Crossover Claim
A claim for which both Titles XVIII (Medicare) and XIX
						  (Medicaid) are liable for reimbursement of services provided to a beneficiary
						  entitled to benefits under both programs
Date of Service
Date or dates on which a beneficiary receives a covered
						  service. Documentation of services and units received must be in the
						  beneficiary's record for each date of service.
Deductible
The amount the Medicare beneficiary must pay toward
						  covered benefits before Medicare or insurance payment can be made for
						  additional benefits. Medicare Part A and Part B deductibles are paid by
						  Medicaid within the program limits.
Debit Claim
A claim transaction which has a positive effect on a
						  previously processed claim
Denial
A claim for which payment is disallowed
Department of Health and Human Services
						  (HHS)
Federal health and human services agency
Department of Human Services (DHS)
State human services agency
Dependent
A spouse or child of the individual who is entitled to
						  benefits under the Medicaid Program
Diagnosis
The identity of a condition, cause or
						  disease
Diagnostic Admission
Admission to a hospital primarily for the purpose of
						  diagnosis
Disallow
To subtract a portion of a billed charge that exceeds
						  the Medicaid maximum or to deny an entire charge because Medicaid pays Medicare
						  Part A and B deductibles subject to program limitations for eligible
						  beneficiaries
Discounts
A discount is defined as the lowest available price
						  charged by a provider to a client or third-party payer, including any discount,
						  for a specific service during a specific period by an individual provider. If a
						  Medicaid provider offers a professional or volume discount to any customer,
						  claims submitted to Medicaid must reflect the same discount.
Example: If a laboratory provider charges a private
						  physician or clinic a discounted rate for services, the charge submitted to
						  Medicaid for the same service must not exceed the discounted price charged to
						  the physician or clinic. Medicaid must be given the benefit of discounts and
						  price concessions the lab gives any one of its customers.
Duplicate Claim
A claim that has been submitted or paid previously or a
						  claim that is identical to a claim in process
Durable Medical Equipment
Equipment that (1) can withstand repeated use and (2)
						  is used to serve a medical purpose. Examples include a wheelchair or hospital
						  bed.
Early and Periodic Screening, Diagnosis and Treatment
						  (EPSDT)
A federally mandated Medicaid program for eligible
						  individuals under the age of 21. See
Child Health
						  Services.
Education Accreditation
When an individual is required to possess a bachelor's
						  degree, master's degree, or a Ph.D. degree in a specific profession. The degree
						  must be from a program accredited by an organization that is approved by the
						  Council for Higher Education Accreditation (CHEA).
Electronic Signature
An electronic or digital method executed or adopted by
						  a party with the intent to be bound by or to authenticate a record, which is:
						  (a) Unique to the person using it; (b) Capable of verification; (c) Under the
						  sole control of the person using it; and (d) Linked to data in such a manner
						  that if the data are changed the electronic signature is invalidated. An
						  Electronic Signature method must be approved by the DHS Chief Information
						  Officer or his designee before it will be accepted. A list of approved
						  electronic signature methods will be posted on the state Medicaid
						  website.
Eligible
(1) To be qualified for Medicaid benefits. (2) One who
						  is qualified for benefits
Eligibility File
A file containing individual records for all persons
						  who are eligible or have been eligible for Medicaid
Emergency Services
Inpatient or outpatient hospital services that a
						  prudent layperson with an average knowledge of health and medicine would
						  reasonably believe are necessary to prevent death or serious impairment of
						  health and which, because of the danger to life or health, require use of the
						  most accessible hospital available and equipped to furnish those
						  services.
Source: 42 U.S. Code of Federal Regulations (42 CFR)
						  and §424.101.
Error Code
A numeric code indicating the type of error found in
						  processing a claim; also known as an "Explanation of Benefits (EOB) code" or a
						  "HIPAA Explanation of Benefits (HEOB) code"
Estimated Acquisition Cost
The estimated amount a pharmacy actually pays to obtain
						  a drug
Experimental Surgery
Any surgical procedure considered experimental in
						  nature
Explanation of Medicaid Benefits (EOMB)
A statement mailed once per month to selected
						  beneficiaries to allow them to confirm the Medicaid service which they
						  received
Family Planning Services
Any medically approved diagnosis, treatment,
						  counseling, drugs, supplies or devices prescribed or furnished by a physician,
						  nurse practitioner, certified nurse-midwife, pharmacy, hospital, family
						  planning clinic, rural health clinic (RHC), Federally Qualified Health Center
						  (FQHC) or the Department of Health to individuals of child-bearing age for
						  purposes of enabling such individuals freedom to determine the number and
						  spacing of their children.
Field Audit
An activity performed whereby a provider's facilities,
						  procedures, records and books are audited for compliance with Medicaid
						  regulations and standards. A field audit may be conducted on a routine basis,
						  or on a special basis announced or unannounced.
Fiscal Agent
An organization authorized by the State of Arkansas to
						  process Medicaid claims
Fiscal Agent Intermediary
A private business firm which has entered into a
						  contract with the Arkansas Department of Human Services to process Medicaid
						  claims
Fiscal Year
The twelve-month period between settlements of
						  financial accounts
Generic Upper Limit (GUL)
The maximum drug cost that may be used to compute
						  reimbursement for specified multiple-source drugs unless the provisions for a
						  Generic Upper Limit override have been met. The Generic Upper Limit may be
						  established or revised by the Centers for Medicare and Medicaid Services (CMS)
						  or by the State Medicaid Agency.
Group
Two or more persons. If a service is a "group" therapy
						  or other group service, there must be two or more persons present and receiving
						  the
service.
Group Practice
A medical practice in which several practitioners
						  render and bill for services under a single pay-to provider identification
						  number
Healthcare Common Procedure Coding System
						  (HCPCS)
Federally defined procedure codes
Health Insurance Claim Number
Number assigned to Medicare beneficiaries and
						  individuals eligible for SSI
Hospital
An institution that meets the following
						  qualifications:
* Provides diagnostic and rehabilitation services to
						  inpatients
* Maintains clinical records on all
						  patients
* Has by-laws with respect to its staff of
						  physicians
* Requires each patient to be under the care of a
						  physician, dentist or certified nurse-midwife
* Provides 24-hour nursing service
* Has a hospital utilization review plan in
						  effect
* Is licensed by the State
* Meets other health and safety requirements set by the
						  Secretary of Health and Human Services
Hospital-Based Physician
A physician who is a hospital employee and is paid for
						  services by the hospital
HP Enterprise Services
Current fiscal agent for the state Medicaid
						  program
ID Card
An identification card issued to Medicaid beneficiaries
						  and ARKids First-B participants containing encoded data that permits a provider
						  to access the card-holder's eligibility information
Individual
A single person as distinguished from a group. If a
						  service is an "individual" therapy or service, there may be only one person
						  present who is receiving the service.
Inpatient
A patient, admitted to a hospital or skilled nursing
						  facility, who occupies a bed and receives inpatient services.
In-Process Claim (Pending Claim)
A claim that suspends during system processing for
						  suspected error conditions such as: all processing requirements appear not to
						  be met. These conditions must be reviewed by HP ENTERPRISE SERVICES or DMS and
						  resolved before processing of the claim can be completed. See
Suspended
						  Claim.
Inquiry
A request for information
Institutional Care
Care in an authorized private, non-profit, public or
						  state institution or facility. Such facilities include schools for the deaf,
						  and/or blind and institutions for the handicapped.
Instrumental Activities of Daily Living
						  (IADL)
Tasks which are ordinarily performed on a daily or
						  weekly basis and include meal preparation, housework, laundry, shopping, taking
						  medications and travel/transportation
Intensive Care
Isolated and constant observation care to patients
						  critically ill or injured
Interim Billing
A claim for less than the full length of an inpatient
						  hospital stay. Also, a claim that is billed for services provided to a
						  particular date even though services continue beyond that date. It may or may
						  not be the final bill for a particular beneficiary's services.
Internal Control Number (ICN)
The unique 13-digit claim number that appears on a
						  Remittance Advice
International Classification of Diseases, Ninth
						  Edition, Clinical Modification (ICD-9CM)
A diagnosis coding system used by medical providers to
						  identify a patient's diagnosis and/or diagnoses on medical records and
						  claims
Investigational Product
Any product that is considered investigational or
						  experimental and that is not approved by the Food and Drug Administration. The
						  Arkansas Medicaid Program does not cover investigational products.
Julian Date
Chronological date of the year, 001 through 365 or 366,
						  preceded on a claims number (ICN) by a two-digit-year designation. Claim number
						  example: 03231 (August 19, 2003).
Length Of Stay
Period of time a patient is in the hospital. Also, the
						  number of days covered by Medicaid within a single inpatient stay.
Line Item
A service provided to a beneficiary. A claim may be
						  made up of one or more line items for the same beneficiary. Also called a claim
						  detail.
Long Term Care (LTC)
An office within the Arkansas Division of Medical
						  Services responsible for nursing facilities
Long Term Care Facility
A nursing facility
Maximum Allowable Cost (MAC)
The maximum drug cost which may be reimbursed for
						  specified multi-source drugs. This term is interchangeable with generic upper
						  limit.
Medicaid Provider Number
A unique identifying number assigned to each provider
						  of services in the Arkansas Medicaid Program, required for identification
						  purposes
Medicaid Management Information System
						  (MMIS)
The automated system utilized to process Medicaid
						  claims
Medical Assistance Section
A section within the Arkansas Division of Medical
						  Services responsible for administering the Arkansas Medical Assistance
						  Program
Medically Needy
Individuals whose income and resources exceed the
						  levels for assistance established under a state or federal plan for
						  categorically needy, but are insufficient to meet costs of health and medical
						  services
Medical Necessity
All Medicaid benefits are based upon medical necessity.
						  A service is "medically necessary" if it is reasonably calculated to prevent,
						  diagnose, correct, cure, alleviate or prevent the worsening of conditions that
						  endanger life, cause suffering or pain, result in illness or injury, threaten
						  to cause or aggravate a handicap or cause physical deformity or malfunction and
						  if there is no other equally effective (although more conservative or less
						  costly) course of treatment available or suitable for the beneficiary
						  requesting the service. For this purpose, a "course of treatment" may include
						  mere observation or (where appropriate) no treatment at all. The determination
						  of medical necessity may be made by the Medical Director for the Medicaid
						  Program or by the Medicaid Program Quality Improvement Organization (QIO).
						  Coverage may be denied if a service is not medically necessary in accordance
						  with the preceding criteria or is generally regarded by the medical profession
						  as experimental inappropriate or ineffective using unless objective clinical
						  evidence demonstrates circumstances making the service necessary.
Mis-Utilization
Any usage of the Medicaid Program by any of its
						  providers and/or beneficiaries which is not in conformance with both State and
						  Federal regulations and laws (includes fraud, abuse and defects in level and
						  quality of care)
National Drug Code
The unique 11-digit number assigned to drugs which
						  identifies the manufacturer, drug, strength and package size of each
						  drug
National Provider Identifier (NPI)
A standardized unique health identifier for health care
						  providers for use in the health care system in connection with standard
						  transactions for all covered entities. Established by the Centers for Medicare
						  & Medicaid Services, HHS, in compliance with HIPAA Administrative
						  Simplification -45 CFR Part 162.
Non-Covered Services
Services not medically necessary, services provided for
						  the personal convenience of the patient or services not covered under the
						  Medicaid Program
Nonpatient
An individual who receives services, such as laboratory
						  tests, performed by a hospital, but who is not a patient of the
						  hospital
Nurse Practitioner
A professional nurse with credentials that meet the
						  requirements for licensure as a nurse practitioner in the State of
						  Arkansas
Outpatient
A patient receiving medical services, but not admitted
						  as an inpatient to a hospital
Over-Utilization
Any over usage of the Medicaid Program by any of its
						  providers and/or beneficiaries not in conformance with professional judgment
						  and both State and Federal regulations and laws (includes fraud and
						  abuse)
Participant
A provider of services who: (1) provides the service,
						  (2) submits the claim and (3) accepts Medicaid's reimbursement for the services
						  provided as payment in full
Patient
A person under the treatment or care of a physician or
						  surgeon, or in a hospital
Payment
Reimbursement to the provider of services for rendering
						  a Medicaid-covered benefit
Pay-to Provider
A person, organization or institution authorized to
						  receive payment for services provided to Medicaid beneficiaries by a person or
						  persons who are a part of the entity
Pay-to Provider Number
A unique identifying number assigned to each pay-to
						  provider of services (Clinic/Group/Facility) in the Arkansas Medicaid Program
						  or the pay-to provider group's assigned National Provider Identifier (NPI).
						  Medicaid reports provider payments to the Internal Revenue Service under the
						  Employer Identification Number "Tax ID" linked in the Medicaid Provider File to
						  the pay-to provider identification number.
Per Diem
A daily rate paid to institutional
						  providers
Performing Physician
The physician providing, supervising, or both, a
						  medical service and claiming primary responsibility for ensuring that services
						  are delivered as billed
Person
Any natural person, company, firm, association,
						  corporation or other legal entity
Place of Service (POS)
A nationally approved two-digit numeric code denoting
						  the location of the patient receiving services
Plan of Care
A document utilized by a provider to plan, direct or
						  deliver care to a patient to meet specific measurable goals; also called care
						  plan, service plan or treatment plan
Postpayment Utilization Review
The review of services, documentation and practice
						  after payment
Practitioner
An individual who practices in a health or medical
						  service profession
Prepayment Utilization Review
The review of services, documentation and practice
						  patterns before payment
Prescription
A health care professional's legal order for a drug
						  which, in accordance with federal and/or state statutes, may not be obtained
						  otherwise; also an order for a particular Medicaid covered service
Prescription Drug (RX)
A drug which, in accordance with federal and/or state
						  statutes, may not be obtained without a valid prescription
Primary Care Physician (PCP)
A physician responsible for the management of a
						  beneficiary's total medical care. Selected by the beneficiary to provide
						  primary care services and health education. The PCP will monitor on an ongoing
						  basis the beneficiary's condition, health care needs and service delivery be
						  responsible for locating, coordinating and monitoring medical and
						  rehabilitation services on behalf of the beneficiary and refer the beneficiary
						  for most specialty services, hospital care and other services.
Prior Approval
The approval for coverage and reimbursement of specific
						  services prior to furnishing services for a specified beneficiary of Medicaid.
						  The request for prior approval must be made to the Medical Director of the
						  Division of Medical Services for review of required documentation and
						  justification for provision of service.
Prior Authorization (PA)
The approval by the Arkansas Division of Medical
						  Services, or a designee of the Division of Medical Services, for specified
						  services for a specified beneficiary to a specified provider before the
						  requested services may be performed and before payment will be made.
Prior authorization does not guarantee reimbursement.
Procedure Code
A five-digit numeric or alpha numeric code to identify
						  medical services and procedures on medical claims
Professional Component
A physician's interpretation or supervision and
						  interpretation of laboratory, X-ray or machine test procedures
Profile
A detailed view of an individual provider's charges to
						  Medicaid for health care services or a detailed view of a beneficiary's usage
						  of health care services
Provider
A person, organization or institution enrolled to
						  provide and be reimbursed for health or medical care services authorized under
						  the State Title XIX Medicaid Program
Provider
Identification
Number
A unique identifying number assigned to each provider
						  of services in the Arkansas Medicaid Program or the provider's assigned
						  National Provider Identifier (NPI), when applicable, that is required for
						  identification purposes
Provider Relations
The activity within the Medicaid Program which handles
						  all relationships with Medicaid providers
Quality Assurance
Determination of quality and appropriateness of
						  services rendered
Quality Improvement Organization
A Quality Improvement Organization (QIO) is a federally
						  mandated review organization required of each state's Title XIX (Medicaid)
						  program. Arkansas Medicaid has contracted with the Arkansas Foundation for
						  Medical Care, Inc. (AFMC) to be its QIO. The QIO monitors hospital and
						  physician services billed to the state's Medicare intermediary and the Medicaid
						  program to assure high quality, medical necessity and appropriate care for each
						  patient's needs.
Railroad Claim Number
The number issued by the Railroad Retirement Board to
						  control payments of annuities and pensions under the Railroad Retirement Act.
						  The claim number begins with a one- to three-letter alphabetic prefix denoting
						  the type of payment, followed by six or nine numeric digits.
Referral
An authorization from a Medicaid enrolled provider to a
						  second Medicaid enrolled provider. The receiving provider is expected to
						  exercise independent professional judgment and discretion, to the extent
						  permitted by laws and rules governing the practice of the receiving
						  practitioner, and to develop and deliver medically necessary services covered
						  by the Medicaid program. The provider making the referral may be a physician or
						  another qualified practitioner acting within the scope of practice permitted by
						  laws or rules. Medicaid requires documentation of the referral in the
						  beneficiary's medical record, regardless of the means the referring provider
						  makes the referral. Medicaid requires the receiving provider to document the
						  referral also, and to correspond with the referring provider regarding the case
						  when appropriate and when the referring provider so requests.
Reimbursement
The amount of money remitted to a provider
Rejected Claim
A claim for which payment is refused
Relative Value
A weighting scale used to relate the worth of one
						  surgical procedure to any other. This evaluation, expressed in units, is based
						  upon the skill, time and the experience of the physician in its
						  performance.
Remittance
A remittance advice
Remittance Advice (RA)
A notice sent to providers advising the status of
						  claims received, including paid, denied, in-process and adjusted claims. It
						  includes year-to-date payment summaries and other financial
						  information.
Reported Charge
The total amount submitted in a claim detail by a
						  provider of services for reimbursement
Retroactive Medicaid Eligibility
Medicaid eligibility which may begin up to three (3)
						  months prior to the date of application provided all eligibility factors are
						  met in those months
Returned Claim
A claim which is returned by the Medicaid Program to
						  the provider for correction or change to allow it to be processed
						  properly
Sanction
Any corrective action taken against a
						  provider
Screening
The use of quick, simple medical procedures carried out
						  among large groups of people to sort out apparently well persons from those who
						  may have a disease or abnormality and to identify those in need of more
						  definitive examination or treatment
Signature
The person's original signature or initials. The
						  person's signature or initials may also be recorded by an electronic or digital
						  method, executed or adopted by the person with the intent to be bound by or to
						  authenticate a record. An electronic signature must comply with Arkansas Code
						  Annotated §
																25-31-101
						  -105, including verification through an electronic signature verification
						  company and data links invalidating the electronic signature if the data is
						  changed.
Single State Agency
The state agency authorized to administer or supervise
						  the administration of the Medicaid Program on a statewide basis
Skilled Nursing Facility (SNF)
A nursing home, or a distinct part of a facility,
						  licensed by the Office of Long Term Care as meeting the Skilled Nursing
						  Facility Federal/State licensure and certification regulations. A health
						  facility which provides skilled nursing care and supportive care on a 24-hour
						  basis to residents whose primary need is for availability of skilled nursing
						  care on an extended basis.
Social Security Administration (SSA)
A federal agency which makes disability and blindness
						  determinations for the Secretary of the HHS
Social Security Claim Number
The account number used by SSA to identify the
						  individual on whose earnings SSA benefits are being paid. It is the Social
						  Security Account Number followed by a suffix, sometimes as many as three
						  characters, designating the type of beneficiary (e.g., wife, widow, child,
						  etc.).
Source of Care
A hospital, clinic, physician or other facility which
						  provides services to a beneficiary under the Medicaid Program
Specialty
The specialized area of practice of a physician or
						  dentist
Spend Down (SD)
The amount of money a beneficiary must pay toward
						  medical expenses when income exceeds the Medicaid financial guidelines. A
						  component of the medically needy program allows an individual or family whose
						  income is over the medically needy income limit (MNIL) to use medical bills to
						  spend excess income down to the MNIL. The individual(s) will have a spend down
						  liability. The spend down column of the remittance advice indicates the amount
						  which the provider may bill the beneficiary. The spend down liability occurs
						  only on the first day of Medicaid eligibility.
Status Report
A remittance advice
Supplemental Security Income (SSI)
A program administered by the Social Security
						  Administration. This program replaced previous state administered programs for
						  aged, blind or disabled beneficiaries (except in Guam, Puerto Rico and the
						  Virgin Islands). This term may also refer to the Bureau of Supplemental
						  Security Income within SSA which administers the program.
Suspended Claim
An "In-Process Claim" which must be reviewed and
						  resolved
Suspension from Participation
An exclusion from participation for a specified period
						  of time
Suspension of Payments
The withholding of all payments due to a provider until
						  the resolution of a matter in dispute between the provider and the state
						  agency
Termination from
A permanent exclusion from participation in the Title
						  XIX Program
Participation
Third Party Liability (TPL)
A condition whereby a person or an organization, other
						  than the beneficiary or the state agency, is responsible for all or some
						  portion of the costs for health or medical services incurred by the Medicaid
						  beneficiary (e.g., a health insurance company, a casualty insurance company or
						  another person in the case of an accident, etc.).
Utilization Review (UR)
The section of the Arkansas Division of Medical
						  Services which performs the monitoring and controlling of the quantity and
						  quality of health care services delivered under the Medicaid
						  Program
Void
A transaction which deletes
Voice Response System (VRS)
Voice-activated system to request prior authorization
						  for prescription drugs and for PCP assignment and change
Ward
An accommodation of five or more beds
Withholding of Payments
A reduction or adjustment of the amounts paid to a
						  provider on pending and subsequently due payments
Worker's Compensation
A type of Third Party Liability for medical services
						  rendered as the result of an on-the-job accident or injury to a beneficiary for
						  which the employer's insurance company may be obligated under the Worker's
						  Compensation Act
Provider Manual Update Transmittal #SecV-4-10
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 aoDlicant:
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
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				to view image
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				to view image
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				to view image
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(9)
County:
From the following list of codes, indicate the county that
			 coincides with the place of service. If the services are provided in a
			 bordering or out-of-state location,
please use the county
			 codes
designated at the end of the code list.
County
County Code
County
Arkansas
01
Garland
Ashley
02
Grant
Baxter
03
Greene
Benton
04
Hempstead
Boone
05
Hot Spring
Bradley
06
Howard
Calhoun
07
Independence
Carroll
08
Izard
Chicot
09
Jackson
Clark
10
Jefferson
Clay
11
Johnson
Cleburne
12
Lafayette
Cleveland
13
Lawrence
Columbia
14
Lee
Conway
15
Lincoln
Craighead
16
Little River
Crawford
17
Logan
Crittenden
18
Lonoke
Cross
19
Madison
Dallas
20
Marion
Desha
21
Miller
Drew
22
Mississippi
Faulkner
23
Monroe
Franklin
24
Montgomery
Fulton
25
Nevada
Louisiana
91
Oklahoma
Missouri
92
Tennessee
Mississippi
93
26
Newton
51
27
Ouachita
52
28
Perry
53
29
Phillips
54
30
Pike
55
31
Poinsett
56
32
Polk
57
33
Pope
58
34
Prairie
59
35
Pulaski
60
36
Randolph
61
37
Saline
62
38
Scott
63
39
Searcy
64
40
Sebastian
65
41
Sevier
66
42
Sharp
67
43
St. Francis
68
44
Stone
69
45
Union
70
46
Van Buren
71
47
Washington
72
48
White
73
49
Woodruff
74
50
Yell
75
94
Texas
96
95
All other states
97
(10)
Provider Category (A-C)
Enter the two-digit
highlighted
code, from the
				following list, which identifies the services the applicant will be
				providing.
A) __________________ B)________________
				C)________________
Code
Category Description
N3
Advanced Practice Nurse - Pediatrics
N4
Advanced Practice Nurse -Women's Health
N6
Advanced Practice Nurse - Family
N7
Advanced Practice Nurse -
						  Adult/Gerontological
N8
Advanced Practice Nurse - Psychiatric Mental
						  Health
N9
Advanced Practice Nurse -Acute Care
NO
Advanced Practice Nurse- Nurse Practitioner-
						  Other
03
Allergy/Immunology
A8
Alternatives for Adults with Physical Disabilities
						  (Alternative) - Environmental Adaptations
A9
Alternatives for Adults with Physical Disabilities
						  (Alternative) - Attendant Care Services
A4
Ambulatory Surgical Center
AA
Adolescent Medicine
05
Anesthesiology
AH
Living Choices Assisted Living Agency
AL
Living Choices Assisted Living Facility-Direct Services
						  Provider
AP
Living Choices Assisted Living Pharmacist
						  Consultant
64
Audiologist
C1
Cancer Screen (Health Dept. Only)
C2
Cancer Treatment (Health Dept. Only)
06
Cardiovascular Disease
C4
Child Health Management Services
CF
Child Health Management Services - Foster
						  Care
35
Chiropractor
C8
Communicable Diseases (Health Dept. Only)
C3
CRNA
HA
DDS ACS Waiver Physical Adaptations
HB
DDS ACS Waiver Specialized Medical Supplies
HC
DDS ACS Waiver Case Management Services
HE
DDS ACS Waiver Supported Employment
H7
DDS ACS Waiver Supportive Living
H8
DDS ACS Waiver Crisis Abatement Services
HG
DDS ACS Waiver Crisis Center- Intervention
						  Services
H9
DDS ACS Waiver Consultation Services
IC
DDS ACS Waiver IndependentChoices
HF
DDS ACS Waiver Organized Healthcare
N5
DDS Non-Medicaid
V2
Dental
V1
Dental Clinic (Health Dept. Only)
X5
Dental - Oral Surgeon
V6
Dental - Orthodontia
07
Dermatology
V3
Developmental Day Treatment Center
DR
Developmental Rehabilitation Services
V5
Domiciliary Care
CN
DYS/TCM Group
CO
DYS/TCM Performing
E4
ElderChoices H&CB 2176 Waiver - Chore
						  services
E5
ElderChoices H&CB 2176 Waiver - Adult Family
						  Homes
E6
ElderChoices H&CB 2176 Waiver - Home
						  maker
E7
ElderChoices H&CB 2176 Waiver - Home delivered hot
						  meals
EC
ElderChoices H&CB 2176 Waiver - Home delivered
						  frozen meals
E8
ElderChoices H&CB 2176 Waiver - Personal emergency
						  response systems
E9
ElderChoices H&CB 2176 Waiver - Adult day
						  care
EA
ElderChoices H&CB 2176 Waiver - Adult day health
						  care
EB
ElderChoices H&CB 2176 Waiver - Respite
						  care
E1
Emergency Medicine
E2
Endocrinology
E3
Early and Periodic Screening, Diagnosis and Treatment
						  (EPSDT)
F1
Family Planning
08
Family Practice
F2
Federally Qualified Health Center
10
Gastroenterology
01
General Practice
38
Geriatrics
16
Gynecology - Obstetrics
H1
Hearing Aid Dealer
H2
Hematology
H5
Hemodialysis
H3
Home Health
H6
Hospice
A5
Hospital - AR State Operating Teaching
						  Hospital
W6
Hospital - Inpatient
W7
Hospital - Outpatient
CH
Hospital - Critical Access
IH
Hospital - Indian Health Services
IS
Hospital - Indian Health Services
						  Freestanding
P7
Hospital - Pediatric Inpatient
P8
Hospital - Pediatric Outpatient
R7
Hospital - Rural Inpatient
HN
Hyperalimentation Enteral Nutrition - Sole
						  Source
H4
Hyperalimentation Parenteral Nutrition - Sole
						  Source
V8
Immunization (Health Dept. Only)
69
Independent Lab
55
Infectious Diseases
W3
Inpatient Psychiatric - under 21
WA
Inpatient Psychiatric - Residential Treatment Unit
						  within Inpatient Psychiatric Hospital
WB
Inpatient Psychiatric - Residential Treatment
						  Center
WC
Inpatient Psychiatric - Sexual Offenders
						  Program
W4
Intermediate Care Facility
W9
Intermediate Care Facility- Infant
						  Infirmaries
W5
Intermediate Care Facility - Mentally
						  Retarded
11
Internal Medicine
L1
Laryngology
M1
Maternity Clinic (Health Dept. Only)
M4
Medicare/Medicaid Crossover Only
Wl
Mental Health Practitioner- Licensed Certified Social
						  Worker
W2
Mental Health Practitioner- Licensed Professional
						  Counselor
R5
Mental Health Practitioner - Licensed Marriage and
						  Family Therapist
62
Mental Health Practitioner- Psychologist
N1
Neonatology
39
Nephrology
13
Neurology
Nl
Nuclear Medicine
N2
Nurse Midwife
N3
Nurse Practitioner- Pediatric
N4
Nurse Practitioner - OB/GYN
N6
Nurse Practitioner- Family Practice
N7
Nurse Practitioner- Gerontological
RK
Offsite Intervention Service - Outpatient Mental and
						  Behavioral Health (ARKids ONLY)
X1
Oncology
18
Ophthalmology
X2
Optical Dispensing Contractor
X4
Optometrist
X6
Orthopedic
12
Osteopathy - Manipulative Therapy
X7
Osteopathy - Radiation Therapy
X8
Otology
X9
Otorhinolaryngology
22
Pathology
37
Pediatrics
P1
Personal Care Services
PA
Personal Care Services /Area Agency on
						  Aging
PD
Personal Care Services / Developmental Disability
						  Services
PE
Personal Care Services / Week-end
PG
Personal Care Services / Level I Assisted Living
						  Facility
PH
Personal Care Services / Level II Assisted Living
						  Facility
R3
Personal Care Services / Residential Care
						  Facility
PS
Personal Care Services: Public School or Education
						  Service Cooperative
P2
Pharmacy Independent
PC
Pharmacy- Chain
PM
Pharmacy- Compounding
PN
Pharmacy - Home Infusion
PR
Pharmacy - Long Term Care / Closed Door
PV
Pharmacy - Administrated Vaccines
P3
Physical Medicine
48
Podiatrist
63
Portable X-ray Equipment
P6
Private Duty Nursing
PF
Private Duty Nursing: Public School or Education
						  Service Cooperative
28
Proctology
P4
Prosthetic Devices
V4
Prosthetic - Durable Medical
						  Equipment/Oxygen
Z1
Prosthetic - Orthotic Appliances
26
Psychiatry
P5
Psychiatry- Child
29
Pulmonary Diseases
R9
Radiation Therapy - Complete
RA
Radiation Therapy - Technical
30
Radiology - Diagnostic
31
Radiology - Therapeutic
R6
Rehabilitative Services for Persons with Mental
						  Illness
RC
Rehabilitative Services for Persons with Physical
						  Disabilities
R1
Rehabilitative Hospital
RJ
Rehabilitative Services for Youth and Children
						  DCFS
RL
Rehabilitative Services for Youth and Children
						  DYS
CR
Respite Care - Children's Medical Services
R4
Rheumatology
R2
Rural Health Clinic - Provider Based
R8
Rural Health Clinic - Independent
						  Freestanding
S7
School Based Health Clinic - Child Health
						  Services
S8
School Based Health Clinic - Hearing
						  Screener
S9
School Based Health Clinic - Vision
						  Screener
SA
School Based Health clinic - Vision & Hearing
						  Screener
W
School Based Mental Health Clinic
SO
School District Outreach for ARKids
S5
Skilled Nursing Facility
W8
Skilled Nursing Facility-Special Services
S6
SNF Hospital Distinct Part Bed
S1
Surgery- Cardio
S2
Surgery - Colon & Rectal
02
Surgery- General
14
Surgery - Neurological
20
Surgery - Orthopedic
53
Surgery - Pediatric
54
Surgery- Oncology
24
Surgery - Plastic & Reconstructive
33
Surgery - Thoracic
S4
Surgery - Vascular
C5
Targeted Case Management - Ages 60 and
						  Older
C6
Targeted Case Management - Ages 00 - 20
C7
Targeted Case Management - Ages 21 - 59
CM
Targeted Case Management - Developmental Disabilities
						  Certification - Ages 00 - 20
T6
Therapy - Occupational
T1
Therapy - Physical
T2
Therapy - Speech Pathologist
TO
Therapy - Occupational Assistant
TP
Therapy - Physical Assistant
TS
Therapy - Speech Pathologist Assistant
A1
Transportation -Ambulance, Emergency
A2
Transportation -Ambulance, Non-emergency
A6
Transportation -Advanced Life Support with
						  EKG
A7
Transportation - Advanced Life Support without
						  EKG
TA
Transportation - Air Ambulance/Helicopter
TB
Transportation - Air Ambulance/Fixed Wing
TD
Transportation - Broker
TC
Transportation - Non-Emergency
TH
Tuberculosis (Health Dept. Only)
34
Urology
V7
Ventilator Equipment
(11)
Certification Code:
This code identifies the type of provider the
			 certification number in field 12 defines. If an entry is made in this field
			 (11), an entry
MUST
be made in field 12 and 13 unless the entry is
			 a 5. Please
check
the appropriate code.
0 =
Mental Health
1 =
Home Health
2 =
CRNA
3 =
Nursing Home
4 =
Other
5 =
Non-applicable
(12)
Certification Number:
If applicable, enter the certification
			 number assigned to the applicant by the appropriate certification
			 board/agency.
A CURRENT COPY OF THIS CERTIFICATION MUST ACCOMPANY THIS
				APPLICATION.
(13)
End
			 Date:
Enter the expiration date of the applicant's current certification
			 number in month/day/year format.
_________/________/_________
MM DD Year
(14)
Fiscal Year:
Enter the
			 date of the applicant's fiscal year end. This date is in month/day format.
_________/________
MM DD
(15)
DEA Number:
If applicable, enter the number assigned to the
			 applicant by the Federal Drug Enforcement Agency. Pharmacies must submit this
			 information to be enrolled.
Required for Pharmacies only
A CURRENT COPY OF THIS CERTIFICATE MUST ACCOMPANY THIS
				APPLICATION.
(16)
End
			 Date:
Enter the expiration date of the current DEA Number in
			 month/day/year format.
_________/________/_________
MM DD Year
(17)
License Number:
If
			 applicable, enter the license number assigned to the applicant by the
			 appropriate state licensure board. If the license issued is a temporary license
			 enter
TEMP.
If the license number is smaller than the fields
			 allowed, leave the last spaces blank.
A CURRENT COPY OF THIS LICENSE MUST ACCOMPANY THIS
				APPLICATION.
(18)
End
			 Date:
Enter the expiration date of the applicant's current license in
			 month/day/year format.
_________/________/_________
MM DD Year
(19)
CLINICAL LABORATORY IMPROVEMENT
			 AMENDMENTS (CLIA):
If applicable, enter the CLIA number assigned to the
			 applicant.
A copy of the CLIA certificate is required in order to have
			 your laboratory test paid.
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