Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.05-038 - Arkansas Medicaid Provider Manuals Section V - DMS-653

Current through Register Vol. 49, No. 6, June, 2024
CONTRACT
TO PARTICIPATE IN THE ARKANSAS MEDICAL ASSISTANCE
				PROGRAM
ADMINISTERED BY THE DIVISION OF MEDICAL SERVICES TITLE
				XIX (MEDICAID)
The following agreement is entered into
				between_______________________________________________, hereinafter called
				Provider, and the Arkansas Department of Health and Human Services, hereafter
				called Department:
l. Provider, in
			 consideration of the covenants therein, agrees to the following:
A. To keep all records, as set forth in the
			 appropriate Arkansas Medicaid Provider Manual, Official Notice and Remittance
			 Advice Message, to fully disclose the extent of services provided to
			 individuals receiving assistance under the State Plan.
B. To make available all records herein
			 specified to satisfy audit requirements under the Program, to furnish all such
			 records for audits conducted periodically by the Department, the Medicaid Fraud
			 Control Unit of the Arkansas Office of the Attorney General, the U.S. Secretary
			 of the Department of Health and Human Services or their designated agents
			 and/or representatives. For all Medicaid beneficiaries, these records include,
			 but are not limited to those records which are defined in Section "A" of this
			 contract. For clients who are not Medicaid beneficiaries, the records that must
			 be furnished are financial records of charges billed to non-Medicaid insurance
			 to ensure that charges billed to Medicaid do not exceed charges billed to
			 non-Medicaid insurance.
1) In connection with
			 this contract each party hereto will receive certain confidential information
			 relating to the other party. For purposes of this contract, any information
			 furnished or made available to one party relating to the financial condition,
			 results of operation, business, customers, properties, assets, liabilities or
			 information relating to the financial condition relating to beneficiaries and
			 providers, including but not limited to protected health information as defined
			 by the Privacy Rule promulgated pursuant to the Health Insurance Portability
			 and Accountability Act (HIPAA) of 1996, is collectively referred to as
			 "Confidential Information."
2) The
			 contract shall safeguard the use and disclosure of information concerning
			 applicants for or beneficiaries of Title XIX services in accordance with 42 CFR
			 Part 431, Subpart F, and shall comply with 45 CFR Parts 160 and 164 and shall
			 restrict access to and disclosure of such information in compliance with
			 federal and state laws and regulations."
C. To accept assignment under Title XVIII
			 (Medicare) in order to receive payment under Title XIX (Medicaid) for any
			 applicable deductible or coinsurance that may be due and payable under Title
			 XIX (Medicaid).
D. To bill Medicaid
			 only after a service has been provided, or as otherwise specified in the
			 appropriate Arkansas Medicaid Provider Manual, Official Notice, or Remittance
			 Advice message.
E. To accept
			 payment from Medicaid as payment in full for a covered service, and to make no
			 additional charges to the beneficiary or accept any additional payment from the
			 beneficiary except cost share (co-pay or deductible amounts) so designated by
			 the Medicaid Program.
F. To take
			 assignment and file claims with third party sources (medical or liability
			 insurance, etc.), and if third party payment is made to the Provider, to
			 reimburse Medicaid up to the amount Medicaid paid for the services; to make no
			 claims against third party sources for services for which a claim has been
			 submitted to Medicaid; and to notify Medicaid of the identity of each third
			 party source discovered after submission of a claim or claims to
			 Medicaid.
G. To make no charge to a
			 beneficiary for a claim or a portion of a claim when a determination that the
			 service was not medically necessary is made based on the professional opinion
			 of appropriate and
Sualified medical persons on a committee that performs peer
				review of Medicaid cases either for the ivision of Medical Services or for the
				Quality Improvement Organization (QIO); except that such charge may be made to
				the beneficiary when he/she has requested the service and has prior knowledge
				that he/she will be responsible for the cost of such service; and to reimburse
				the Division of Medical Services for all monies paid for claims for services
				that later were determined "not medically necessary."
H. To provide all services without
			 discrimination on the grounds of race, color, national origin, or physical or
			 mental 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.
I. To
			 accept all changes legally made in the Program, and recognize and abide by such
			 changes upon being notified by the Medicaid Program in the form of an update
			 to, or an Official Notice/Remittance Advice Message pertaining to, the
			 appropriate Arkansas Medicaid Provider Manual.
J. That the Department has furnished the
			 Provider with a copy of the Arkansas Medicaid Provider Manual containing the
			 rules, regulations and procedures pertaining to his/her profession. The
			 Provider agrees that the terms and conditions contained therein shall be a part
			 of this contract if the same were set out verbatim herein. The Provider states
			 that he/she is currently licensed to practice in Arkansas or within the State
			 where services were rendered and agrees to promptly notify the Department if
			 his/her license is revoked or suspended. The Provider acknowledges by signature
			 on this contract that he/she has received a copy of the appropriate Arkansas
			 Medicaid Provider Manual.
K. To
			 conform to all Medicaid requirements covered in Federal or State laws,
			 regulations or manuals.
L. To
			 certify by
original
signature within 48 hours of
			 claims being submitted by an electronic media, a claim count and dollar amount
			 billed, that the information on the claims submitted is true, accurate and
			 complete. The Provider agrees to maintain this certification as a matter of
			 record for all claims submitted electronically, by any media.
M. To notify the Department before any change
			 of ownership or operating status. Upon change of ownership or operating status
			 the successor owner or operator shall, as a condition of assumption of this
			 agreement, hold the Department harmless for any rate or payment increases,
			 decreases, or adjustments without respect to whether the increase, decrease, or
			 adjustment relates to services delivered before the change in ownership or
			 operating status.
N. FOR HOSPITALS
			 ONLY
To understand that the Quality Improvement Organization
				(Arkansas Foundation for Medical Care, Inc.) is responsible for the review of
				Medicaid admissions to inpatient hospitals, specifically for length of stay
				purposes, medical necessity and as otherwise specified in the Memorandum of
				Understanding between the individual hospital and Arkansas Foundation for
				Medical Care, Inc.