pcp packet - afmc...2018/12/19 · “lock-out” feature is selected in mmis to prevent the...
TRANSCRIPT
3RD QUARTER, SFY 2019 • JAN. 1–MARCH 31, 2019
PCP Packet FOR MORE INFORMATION, CONTACT:Tonyia Haynes, Supervisor, Outreach Logistics
501-212-8686 • [email protected]
On the web: afmc.org/PCPUpdatePacketsAFMC Provider Relations
Outreach Specialists Contact Information
Click below to view any of the materials in this quarter’s packet. Note: Some links will open a webpage.
Arkansas Health Care Payment Improvement Initiative (AHCPII): paymentinitiative.org
n Episodes of Care• Tonsil update
n PCMH• Addendum: paymentinitiative.org/pcmh-manual-and-additional-
resources• Manual: paymentinitiative.org/pcmh-manual-and-additional-
resources• Questions: [email protected]
Arkansas Works
n New age range
n County resourcesardhs.sharepointsite.net/ARWorks/county_map/index.html
n Educational toolsafmc.org/product/arkansas-works-work-requirement-poster/
Connect Care
n Benefit plan 06IABP: PCP assignment NOT required
n Crosswalk
n DMS-2609 PCP selection/change form
n Dismissal of a beneficiary
n Dual eligible beneficiary• cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/downloads/Medicare_Beneficiaries_Dual_Eligibles_At_a_Glance.pdf
• PCP assignment NOT required
n Foster care
n Voice response system
Extension of Benefits: Benefit Limit
n Review Pointafmc.org/reviewpoint/
n No paper, no phone calls, no fax machines, secure submission
n RA message – vendor change
PASSE
n Delay
n Provider Handbook
n Provider Resourceshumanservices.arkansas.gov/about-dhs/dms/passe-provider-info/passe-resources-for-providers
Provider Enrollment
n Needed documents for application
n Webinar (November 2018)afmc.org/health-care-professionals/arkansas-medicaid-providers/mmis-outreach-specialists/mmis-training-education/mmis-provider-enrollment-revalidation-webinar/
Referrals
n Emergency department
AFMC DEVELOPED THIS MATERIAL UNDER CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. WE ARE NOT PROVIDING LEGAL OR PROFESSIONAL MEDICAL ADVICE. WE MAKE NO WARRANTY, EXPRESSED OR IMPLIED, ON ANY SUBJECT INCLUDING COMPLETENESS AND FITNESS OF THE INFORMATION FOR ANY PURPOSE. THE INFORMATION PRESENTED IN THIS MATERIAL IS CONSISTENT WITH DHS POLICY AS OF SEPTEMBER 2017. IF ANY ARKANSAS DHS POLICY CHANGES MADE AFTER SEPTEMBER 2017 ARE INCONSISTENT
WITH THIS MATERIAL, THE POLICY CONTROLS. ARKANSAS DHS IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. REVISED DECEMBER 2018.
ARKANSAS DEPARTMENTOF HUMAN SERVICES,
DIVISION OF MEDICAL SERVICES
AFMC OUTREACH SPECIALISTS
ARKANSAS MEDICAL SOCIETYREPRESENTATIVE
DXC Technology Services (Claims Processing)500 President Clinton Ave., Suite 400 • Little Rock, AR 72201
Provider Relations Outreach Specialists Information Sheet1020 W. 4th St., Suite 300 • Little Rock, AR 72201 • Toll free: 1-877-650-2362 • Transportation Helpline: 1-888-987-1200
ARKANSAS
ASHLEY
BAXTERBENTON BOONE
BRADLEY
CALHOUN
CARROLL
CHICOT
CLARK
CLAY
CLEBURNE
CLEVELAND
COLUMBIA
CONWAY
CRAIGHEAD
CRAWFORD
CRITTENDENCROSS
DALLASDESHA
DREW
FAULKNER
FRANKLIN
FULTON
GARLAND
GRANT
GREENE
HEMPSTEAD
HOT SPRING
HOWARD
INDEPENDENCE
IZARD
JACKSON
JEFFERSON
JOHNSON
LAFAYETTE
LAWRENCE
LEE
LINCOLN
LITTLERIVER
LOGAN
LONOKE
MADISON
MARION
MILLER
MISSISSIPPI
MONROEMONTGOMERY
NEVADA
NEWTON
OUACHITA
PERRY
PHILLIPS
PIKE
POINSETT
POLK
POPE
PRAIRIE
PULASKI
RANDOLPH
ST. FRANCIS
SALINE
SCOTT
SEARCY
SEBASTIAN
SEVIER
SHARP
STONE
UNION
VAN BUREN
WASHINGTON
WHITEWOODRUFF
YELL
Refer to the map and the color key below to find your representative.
ARKIDS FIRST/MEDICAIDMEDICAL ASSISTANCE
ManagerSheryl Hurt [email protected] [C] 501-804-3168
Supervisor, Provider Relations Tabitha Kinggard ... 501-804-3277 [email protected]
Outreach SpecialistsEmily Alexander ......... [email protected]
Shawna Branscum [email protected]
Kimberly Breedlove [email protected]
Jackie [email protected]
Kellie Cornelius [email protected]
Carla Hestir [email protected]
Connie Riley [email protected]
• Provider Assistance Center (PAC)
• In-state toll free ......... 800-457-4454 • Local / out-of-state ... 501-376-2211
• Provider Enrollment
DXC Technology ServicesP.O. Box 8105 • Little Rock, AR 72203-8105
• Central Arkansas .......... 501-376-2211• Fax .................................... 501-374-0746
https://medicaid.mmis.arkansas.gov
• ARKids First Enrollment Information ................... 888-474-8275
CONNECTCARE• Toll free ........................... 800-275-1131
MEDICAID FRAUD CONTROLUNIT (PROVIDERS)• Central Arkansas .......... 501-682-8349
VOICE RESPONSE SYSTEM• Toll free ........................... 800-805-1512
AFMC SERVICE CENTER (BENEFICIARIES)• Toll free ........................... 888-987-1200
PCMH QUESTIONS [email protected]
MAGELLAN MEDICAID ADMINISTRATION• Pharmacy Help Desk .. 800-424-7895 Prescribers, Option 2
THIRD PARTY LIABILITY• Local ................................. 501-537-1070• Fax .................................... 501-682-1644DHS Division of Medical Services,TPL Unit • P.O. Box 1437, Slot S296Little Rock, AR 72203-1437
PHYSICIAN OUTREACH SPECIALISTGloria Boone .................... [email protected]
10/30/18
Episodes of Care Bulletin Date: November 15, 2018 Distribution: Tonsillectomy providers
Health Care Innovation Arkansas Medicaid AHCPII Help Desk
Email: [email protected] Telephone: 501.301.8311 or 866.322.4946
www.paymentinitiative.org
Irregularities in the Tonsillectomy Episode A review of the 2018 APR PAP Report has revealed incorrect cost calculations. These issues appear to be a lingering effect of the implementation of the new Medicaid Management Information System. The resulting investigation revealed two issues that caused the inflated average adjusted episode cost:
1. A significantly more expensive brand name medication, Ciprodex, was added to the preferred drug list in 2016 and is commonly prescribed when ear tubes are inserted during a tonsillectomy/adenoidectomy. The added cost of this medication was outside the tolerance of the episode’s thresholds.
2. Guidelines for ambulatory surgery centers (ASC) billing was changed in 2016 and the increase in billing preferences caused additional pressure on the episode thresholds.
Currently all costs of medication prescribed by the episode’s principal accountable provider has been included into the costs calculations of the episode. A change in identifying prescribed medications is being implemented. When ear tubes are inserted during a tonsillectomy/adenoidectomy, the medication prescribed for the ear tube is included in the costs. The new method will look at the prescribed medication and its drug classification to determine whether the medication is related to a tonsillectomy and/or an adenoidectomy regardless of the prescribing physician. Other medications such as pain medication or oral antibiotics, would come into cost during the episode duration because of the relevance to a tonsillectomy/adenoidectomy procedure. Please note, very little medication is observed in this episode regarding the actual tonsillectomy/adenoidectomy. A change in identifying additional and supplementary billed charges is also being addressed in response to the change in billing practices by ambulatory surgery centers. The new method will modify the episode to ignore all billed charges for tympanostomies. The updated episode programming will be in place for the January 2019 Performance period and the April 2019 reconciliation report. Below are some important things to know regarding the upcoming reconciliation and performance reports. Reconciliation Report • Any adjudicated negative incentive or risk share amount in the 2018 APR PAP Reconciliation Report has been negated. Recovery of
any risk share has been stopped. • The reconciliation of the 2018 APR PAP Performance Report (which will be run in 2019 APR) will recalculate and adjust any
necessary cost calculations. • In reconciliation, any downward shift of a PAP’s cost category (commendable, acceptable, or non-acceptable) will be ignored.
Increases in gain share will be honored. A preliminary and estimated financial determination will be available before the reconciliation report is released in 2019 April.
• All PAPs will be viewed as passing quality measures regardless of portal entries for only this reconciliation run. We invite you to complete your quality measures as portal entries will be evaluated.
Current Performance Period:
• The 2019 JAN PAP Report for the current performance period will report correct results. • “Passing” quality measures will be enforced for the 2019 APR Performance (payment) report to be eligible for a positive incentive
payment (gain share). • The 2019 APR Performance (payment) report is scheduled for release on April 30, 2019. Additional information about Episodes of Care is located on the Arkansas Health Care Payment Improvement Initiative (AHCPII) website: http://www.paymentinitiative.org. One may also contact the AHCPII Help Desk at 501.301.8311 or [email protected].
Aid Category 06 Description of Plans
• Medicaid for Medically Frail: o Benefit Plan Code: FRAIL o Benefit Plan Description: Full Medicaid for Medically Frail o Used for beneficiaries with traditional Medicaid benefit limits - PCP assignment is
required. • Interim Alternative Benefit Plan (IABP) Medicaid:
o Benefit Plan Code: IABP o Benefit Plan Description: Interim Alternative Benefit Plan o Used while plan determination is finalized. During this time, the beneficiary will
have no limits on physician office visits, labs, or prescriptions – PCP assignment is NOT required. Please do NOT submit a PCP selection/change form to ConnectCare, your local DHS office or your AFMC Provider Relations Representative, as PCP assignment is NOT required.
• Alternative Benefit Plan (ABP) Full Medicaid: o Benefit Plan Code: ABP o Benefit Plan Description: ABP o Used when the beneficiary is in the alternative benefit plan and has no limits on
prescriptions, labs, or physician office visits – PCP assignment is required. • Health Care Independence (Private Option)
o Benefit Plan Code: HCIP o Benefit Plan Description: Health Care Independence (Private Option) the
crosswalk states Private Option – should it be changed to Arkansas Works o Used when the beneficiary has selected a commercial carrier plan. The carrier
name and phone number will be available on the eligibility strip to assist providers with benefits.
ARKANSAS MEDICAID PRIMARY CARE PHYSICIAN MANAGED CARE PROGRAM PRIMARY CARE PHYSICIAN SELECTION AND CHANGE FORM
Member Information:
First Name ______________________ Last Name _________________________ Middle Initial ____________
Medicaid ID# ______________________________ Social Security # __________________________________
Birth Date (mm/dd/yyyy) _____________________
Mailing Address ____________________________ City _____________________ State ____ Zip ________
Home Phone ______________________________ Cell Phone __________________________
Email address __________________________________________________________________
Requested New Doctor (Primary Care Provider):
I have picked the three (3) physicians named below in order of my preference to be my primary care physician. I understand only one (1) of them will be my primary care physician.
1. ____________________________ _____________________ ________________ Doctors first and last name Medicaid Provider ID# Date of assignment
2. ____________________________ _____________________ ________________ Doctors first and last name Medicaid Provider ID# Date of assignment
3. ____________________________ _____________________ ________________ Doctors first and last name Medicaid Provider ID# Date of assignment
Reason for Request to Assign/Change Doctor (Primary Care Provider) Choose all that apply. Select at least one.
� New Member – made 1st time selection � Already patient with requested PCP � Requested PCP already sees family member � Member preference � Member moved � PCP hours didn’t fit member need � Quality of care � Office wait times are too long � Takes too long to get an appointment � Office too far away/ hard to get to � Language / communication barrier � Other (please specify) ___________________________________________________________
Signatures:
Member Signature (or Legal Guardian if a minor) __________________________________________________________
Printed Name of Member (or Legal Guardian if a minor) _____________________________________________________
Date (mm/dd/yyyy) ___________________________________________________________________________________
DMS-2609 (Rev. 10/18)
Primary Care Physician (PCP) Transfer by PCP Request A PCP can request the transfer of a Medicaid beneficiary following the process described in section 173.620 of the Arkansas Medicaid manual. The PCP should hold the dismissal letter until the 30 days are up. In addition to providing a copy to the enrollee’s local DHS office, a copy should also be provided to your AFMC Provider Relations Representative. When a Medicaid beneficiary is dismissed by their assigned PCP, a “lock-out” feature is selected in MMIS to prevent the beneficiary from choosing the dismissing PCP in the future.
173.620 PCP Transfers by PCP Request 9-15-09
A PCP may request that an individual transfer his or her PCP enrollment to another PCP because the arrangement with that individual is not acceptable to the PCP.
A. Examples of unacceptable arrangements include, but are not limited to, the following.
1. The enrollee fails to appear for 2 or more appointments without contacting the PCP before the scheduled appointment time.
2. The enrollee is abusive to the PCP. 3. The enrollee does not comply with the PCP’s medical instruction.
B. At least 30 days in advance of the effective date of the termination, the PCP must give the enrollee written notice to transfer his or her enrollment to another PCP.
1. The notice must state that the enrollee has 30 days in which to enroll with a different PCP.
2. The PCP must forward a copy to the enrollee and to the local DHS office in the enrollee’s county of residence.
C. The PCP continues as the enrollee’s primary care physician during the 30 days or until the individual transfers to another PCP, whichever comes first.
Dual Eligible Beneficiaries Do NOT Require PCP Assignment
172.200 Medicaid-Eligible Individuals Who May not Enroll with a PCP 1-1-16
All Medicaid-eligible participants must enroll with a PCP unless they:
A. Have Medicare as their primary insurance.
B. Are in a long term care aid category and a resident of a nursing facility.
C. Reside in an intermediate care facility for individuals with intellectual disabilities (ICF/IID).
D. Are in a Medically Needy Spend Down eligibility category.
E. Only have a retroactive eligibility period.
1. Medicaid does not require PCP enrollment for the period between the beginning of the retroactive eligibility segment and the fifth day (inclusive) following the eligibility authorization date.
2. If eligibility extends beyond the fifth day following the authorization date, Medicaid requires PCP enrollment unless the beneficiary is otherwise exempt from PCCM requirements.
Foster Care Intake Physical Examination
214.300 Foster Care Intake Physical Examination in the EPSDT Program 10-1-08
Arkansas Medicaid beneficiaries entering the Arkansas foster care system are required to receive an intake physical examination within the first seventy two (72) hours. If the EPSDT provider who performs the screening is not the beneficiary’s PCP, the intake physical examination should be billed with procedure codes 99381-99385 and modifiers EP and H9. Billing with these procedure codes and modifiers will allow the claim to be submitted for payment without a referral from the beneficiary’s PCP and will alert the system not to count the screen toward the beneficiary’s yearly EPSDT periodic complete medical screening limits.
If the EPSDT provider who performs the screen is the beneficiary’s PCP, the intake physical exam should be billed with procedure codes 99391-99395 and modifiers EP and H9. Billing with these procedure codes and modifiers will allow the claim to be submitted for payment and will not count toward the beneficiary’s yearly EPSDT periodic complete medical screening limits.
Procedure codes 99381-99385 and 99391-99395, in conjunction with the EP and H9 modifiers, are to be used only for the required intake physical examination for Medicaid beneficiaries in the Arkansas foster care system.
Voice Response System (VRS) Update
Providers may use the Voice Response System (VRS) to assign a primary care provider (PCP) if the patient doesn’t have a PCP already assigned. This system can be reached by calling 1-800-805-1512.
It is important to follow the process in the Arkansas Medicaid manual to obtain a complete DMS-2609 form (PCP selection/change) prior to assignment. If a PCP assignment is made through the VRS, please do NOT submit the form to your local DHS office, ConnectCare, or your AFMC Provider Relations Representative. The PCP must retain a copy of the form in the enrollee’s file. The PCP change form is in section V of the Arkansas Medicaid manual. Download PCP Change/Selection Form
Currently, retro assignment is NOT allowed when using the VRS. The provider must enter the assignment the day services are received. If a retro assignment date is needed, the PCP can fax the DMS-2609 form to AFMC for assistance with the assignment.
173.100 PCP Selection and Enrollment at Local County DHS Offices 9-15-09
A. Medicaid applicants receive from DHS county office staff, a description and explanationof ConnectCare.
1. By means of a Primary Care Physician Selection and Change form (DMS-2609 orDCO-2609,) an applicant indicates the first, second and third choice for PCPs ofeach family member included in the Medicaid case.
2. Individuals applying for ARKids First-A and B indicate their PCP preferences on themail-in application (form DCO-995).
3. Family members may choose the same PCP whenever there is a PCP available thatcan serve all eligible family members.
B. When eligibility is determined, a DHS worker uses a web-based program or a telephonicvoice response system to enroll the beneficiary with a PCP, beginning with eachbeneficiary/participant’s first choice.
1. If the first choice has a full caseload, the worker tries the second choice and soon.
2. The county office forwards confirmation of PCP enrollment to each new enrollee.
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 andChange 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 theinstructions. 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 orwhen 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 anyamount, at any time, up to the default maximum by submitting a signed requestto their Medicaid Managed Care Services (MMCS) Provider RelationsRepresentative or, on-line through the Medicaid websitehttps://medicaid.mmis.arkansas.gov/ Provider Enrollment Information, Access tothe Provider Information Portal.
2. Prior to making the request for an increase of a caseload that is already at maximum, thePCP is encouraged to review their caseload using the AMII (Arkansas Medicaid InformationInterchange) web portal for inactive patients, to determine if those patients should be removedfrom their caseload. An increase in PCP caseload above the default maximum requires a writtenrequest to the Provider Relations Representative. View or print Provider RelationsRepresentative contact information.
173.400 PCP Selection and Enrollment at Participating Hospitals 7-1-05
Arkansas Medicaid pays acute care hospitals for helping Medicaid beneficiaries enroll with PCPs.
A. Enrollment is by means of a Primary Care Physician Selection and Change form (DMS-2609 or DCO-2609) and the voice response system (VRS).
1. Hospital personnel enter the PCP selection via the VRS. 2. The enrollment is effective immediately upon its acceptance by the online
transaction processor (OLTP) that interfaces with the VRS. 3. The OLTP automatically updates the Medicaid Management Information System
(MMIS) within 24 hours, but in the meantime, the enrollment information is part of the Medicaid eligibility file in the system.
B. The effective date of the PCP enrollment is the date the enrollment is electronically accepted.
C. The enrollee may request and receive a copy of the completed selection form.
D. Hospital staff must forward a copy of the selection form to the PCP accepted by the VRS.
Primary Care Physician (PCP) Enrollment Voice Response System VRS 1-800-805-1512
Arkansas Foundation for Medical Care, Provider Relations Representative Contact Address
Provider Relations Manager Outreach Services
1020 West 4th Street, Suite 300
Little Rock, AR 72201
Telephone
Fax
(501) 212-8686
(501) 375-0705
E-mail address [email protected]
Link Provider Relations Outreach Specialists
Extension of Benefits Effective Feb. 1, 2005, AFMC began review of Medicaid EOB requests for clinical, outpatient, laboratory and X-ray services. Requests are considered only after the service(s) have been rendered and a claim is filed and subsequently denied because the patient’s benefit limits have been exhausted. Medicaid has a benefit limit per state fiscal year of:
• $500 for lab and X-ray • 12 physician visits (in a physician’s office, patient’s home or nursing home) • 12 outpatient hospital visits (non-emergency ER visits, therapy services and related
physician services) • Providers have the option of filing the EOB request on behalf of their recipients.
220.000 Benefit Limits 7-1-15
Benefit limits are the limits on the quantity of covered services Medicaid-eligible beneficiaries may receive. Medicaid-eligible beneficiaries are responsible for payment for services beyond the established benefit limits, unless the Division of Medical Services (DMS) authorizes an extension of a particular benefit
If a service is denied for exceeding the benefit limit, and the Medicaid beneficiary had elected to receive the service by written informed consent prior to the delivery of the service, the Medicaid beneficiary is responsible for the payment, unless that service has been deemed not medically necessary.
Benefit extensions are considered after the service has been rendered and the provider has received a denial for “benefits exhausted.” DMS considers requests for benefit extensions based on the medical necessity of the service. If a Medicaid provider chooses to file for an extension of benefits and is denied due to the service not being medically necessary, the beneficiary is not responsible for the payment. Once the extension of benefits request has been initiated on a particular service, the provider cannot abort the process before a final decision is rendered.
Please see Section 229.000 through Section 229.120 and Section 131.000 points A and C for benefit extension request procedures. DMS reviews extension of benefits requests for Home Health, personal care, diapers and medical supplies. AFMC reviews extension of benefits requests for physician, lab, radiology and machine tests, using form DMS-671. All personal care services for beneficiaries under age 21 are reviewed by the contracted Quality Improvement Organization (QIO). View or print AFMC contact information.
229.100 Extension of Benefits for Laboratory and X-Ray, Physician Office and Outpatient Hospital Services
2-1-05
A. Requests for extension of benefits for laboratory and x-ray, physician and outpatientservices must be mailed to Arkansas Foundation for Medical Care, Inc. (AFMC),Attention EOB Review. View or print the Arkansas Foundation for Medical Care, Inc.contact information.
1. Requests for extension of benefits are considered only after a claim is filed and isdenied because the patient’s benefit limits are exhausted.
2. Submit with the request a copy of the Medical Assistance Remittance and StatusReport reflecting the claim’s denial for exhausted benefits. Do not send a claim.
B. A request for extension of benefits must be received by AFMC within 90 calendar daysof the date of benefits-exhausted denial.
1. Requests for extension of benefits are considered only after a claim is filed and isdenied because the patient’s benefit limits are exhausted.
2. Submit with the request a copy of the Medical Assistance Remittance and StatusReport reflecting the claim’s denial for exhausted benefits. Do not send a claim.
229.110 Completion of Request Form DMS-671, “Request For Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services”
7-1-07
Requests for extension of benefits for Clinical Services (Physician’s Visits), Outpatient Services (Hospital Outpatient visits), Laboratory Services (Lab Tests) and X-ray services (X-ray, Ultrasound, Electronic Monitoring - e.e.g.; e.k.g.; etc-), must be submitted to AFMC for consideration. Consideration of requests for extension of benefits requires correct completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray (form DMS-671). View or print form DMS-671.
Complete instructions for accurate completion of form DMS- 671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each Provider Manual.
229.120 Documentation Requirements 2-1-05
A. To request extension of benefits for any benefit limited service, all applicable records that support the medical necessity of extended benefits are required.
B. Documentation requirements are as follows.
1. Clinical records must: a. Be legible and include records supporting the specific request b. Be signed by the performing provider c. Include clinical, outpatient and/or emergency room records for dates of
service in chronological order d. Include related diabetic and blood pressure flow sheets e. Include a current medication list for the date of service f. Include the obstetrical record related to a current pregnancy when
applicable g. Include clinical indication for laboratory and x-ray services ordered with a
copy of orders for laboratory and x-ray services signed by the physician 2. Laboratory and radiology reports must include:
a. Clinical indication for laboratory and x-ray services ordered b. Signed orders for laboratory and radiology services c. Results signed by the performing provider d. Current and all previous ultrasound reports, including biophysical profiles
and fetal non-stress tests when applicable
Arkansas Foundation for Medical Care, Retrospective Review for Therapy and Prior Authorization for Personal Care for Under Age 21
General telephone contact, local or long distance - Fort Smith
(479) 649-8501 877-650-2362
Fax (479) 649-0799
Mailing address
Arkansas Foundation for Medical Care (AFMC) ATTN: Jarrod E. McClain, RN, CPHM Director, Clinical Review PO Box 180001 Fort Smith, AR 72918-0001
Email address [email protected] or [email protected]
Physical site location 1000 Fianna Way Fort Smith, AR 72919-9008
Office hours 8:00 a.m. until 4:30 p.m. (Central Time), Monday through Friday, except holidays
Arkansas Foundation for Medical Care In-state and out-of-state toll free for inpatient reviews only
1-800-426-2234
General telephone contact, local or long distance - Fort Smith
(479) 649-8501 1-877-650-2362
Fax for CHMS only (479) 649-0776
Fax (479) 649-0799
Mailing address Arkansas Foundation for Medical Care, Inc PO Box 180001 Fort Smith, AR 72918-0001
Physical site location 5111 Rogers Avenue, Suite 476 Fort Smith, AR 72903
Office hours 8:00 a.m. until 4:30 p.m. (Central Time), Monday through Friday, except holidays
REQUEST FOR EXTENSION OF BENEFITS FOR CLINICAL, OUTPATIENT, LABORATORY AND X-RAY SERVICES
Arkansas Foundation for Medical Care, Inc. Attn: EOB Review P O Box 180001 DATE: ____/____/____ Fort Smith, AR 72918-0001
DMS-671 [Rev.10/15]
Important: If all required information is not completed, the form will be returned to provider.
(1) PERFORMING PROVIDER
(2) PROVIDER ID#/TAXONOMY CODE
(3) MAILING ADDRESS (4) GROUP PROVIDER ID # ___ ___ ___ ___ ___ ___ ___ ___ ___
CITY STATE ZIP CODE
(5) PERFORMING PROVIDER SIGNATURE & CREDENTIALS
Request Disposition Completed By
AFMC
(10)
SERVICE
FROM
DATE
(11)
SERVICE
TO
DATE
(12)
DIAGNOSIS
CODE
(13)
DIAGNOSIS CODE DESCRIPTION
(14)
PROCEDURE
CODE
(15)
PROCEDURE CODE DESCRIPTION
(16)
UNITS
DECISION
DATE OF
REVIEW
APPROVED
DENIE
D
Benefit Extension Control # _______________________________
Completed by AFMC Note: Attach copies of Medical Records/Supporting Documentation substantiating medical necessity of requested services/procedures.
[Instructions for requesting extension of benefits and completion of this form are included on the reverse side of this form.] Comments:
(6) BENEFICIARY NAME [ LAST] [FIRST] [M.I.]
(7) ADDRESS CITY STATE ZIP CODE
(8) MEDICAID BENEFICIARY ID (10 digits) ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
(9) DOB MM/DD/YY SEX ____/____/_____ _______
To file a Request for Extension of Benefits, the following information is required:
Requirements for Requests for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services
Procedural Policy To reduce delays in processing requests and to avoid returning requests due to incomplete and/or lack of documentation, the following procedures must be followed. I. Requests for extension of benefits will be considered after a claim has been denied for exceeding the benefit limit. II. The Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services (Form DMS-671)
must be filed within 90 calendar days of the date of denial. Any request filed beyond the 90 calendar day deadline will be denied.
III. Extension of benefits will be denied if the original claim was denied for untimely filing (12 months beyond the date of service).
IV. AFMC EOB Review will consider extending benefits if all of the following documentation is received with request. A. All fields of form DMS-671 must be correctly completed by entering the following information: (1) Enter performing provider’s name. (2) Enter the provider ID # and taxonomy code of performing provider. (3) Enter the address provider will use to receive correspondence regarding this extension. (4) If the provider is a member of a group, enter the group provider ID #. (5) Performing provider’s signature and credentials must be entered in this field. (6) Enter the beneficiary’s full name. (7) Enter the beneficiary’s complete address. (8) Enter the beneficiary’s Medicaid ID #. (9) Enter the beneficiary’s date of birth and sex. (10) Enter the service from date. (11) Enter the service to date. (12) Enter the diagnosis code. (13) Enter the diagnosis code description. (14) Enter the procedure code and applicable modifier(s). (If there are more than 4 procedures, additional
procedures must be added to a separate completed form.) (15 )Enter the procedure code description. (16) Enter the number of units. B. Copy of the Medical Assistance Remittance and Status Report stating benefits are exhausted for date of
service. Do not send the claim form. C. Clinical records must:
1. Be legible and include records supporting the specific request 2. Be signed by the performing provider 3. Include clinical, outpatient and/or emergency room records for dates of service in chronological order 4. Include related diabetic and blood pressure flow sheets 5. Include current medication list for date of service 6. Include obstetrical record related to current pregnancy
D. Laboratory and radiology reports must include: 1. Clinical indication for lab and x-ray ordered 2. Signed orders for laboratory and radiology 3. Results signed by performing provider 4. Current and all previous ultrasound reports, including biophysical profiles and fetal non-stress tests
E. The Arkansas Medicaid Program automatically extends benefits when one of the following diagnoses exists and is entered as the primary diagnosis in both header and detail fields: 1. Malignant neoplasm 2. HIV, including AIDS 3. Renal failure 4. Pregnancy, excluding OB ultrasounds and Fetal Non-Stress Tests
F. Requests for reconsideration must be received within 30 calendar days of AFMC denial. Only one reconsideration will be allowed.
G. AFMC reserves the right to request further clinical documentation as deemed necessary to complete medical review.
Messages for Remittance Advices dated December 6, 2018 – December 13, 2018 TO: ALL PROVIDERS RE: VENDOR CHANGE FOR PRIOR AUTHORIZATION AND EOB REQUESTS Vendors for certain prior authorizations and extension of benefits will change effective January 1, 2019. To help you prepare for this change, training will be offered via the web. Register now to learn more about these webinars at https://medicaid.mmis.arkansas.gov/Provider/Training/Training.aspx.
If you need this material in an alternative format such as large print, please contact the Office of Rules Promulgation at (501) 320-6429.
Thank you for your participation in the Arkansas Medicaid Program. If you have questions regarding these messages, please contact the Provider Assistance Center at 1-800-457-4454 (toll-free) within Arkansas or locally and out-of-state at (501) 376-2211. Remittance Advices can be found using Search Payment History on the Arkansas Medicaid Provider Portal at https://portal.mmis.arkansas.gov/ARMedicaid/Provider.
Prior Authorization and Extension of Benefit PAs and/or EOBs will be requested through eQHealth Solutions beginning on 1/1/19 for the following services:
• Occupational, Physical, and Speech Therapy Services • Early Intervention Day Treatment (EIDT) • Outpatient Behavioral Health Services (OBHS) Tier 1 • School-Based Mental Health Services • Infant Mental Health
PAs, certifications of need, continued stays, and/or EOBs will be requested through eQHealth Solutions beginning on 1/1/19 for the following services:
• Inpatient Acute for Under Age 21
Confirmations and/or EOBs should continue to be requested through Beacon Health Options until 2/28/19 for the following services:
• Outpatient Behavioral Health Services (OBHS) Tier 2 and 3 • Psychiatric Residential for Under Age 21
PASSEs have been providing care coordination for clients in 2018 and were set to be responsible for paying for members’ care starting January 1, 2019, as part of Phase II of the implementation. Following discussions and feedback from stakeholders, DHS and the PASSEs have agreed to allow extra time for the PASSEs to take on those responsibilities. The updated start date is March 1, 2019. 1) Why is the extra time needed? DHS and the PASSEs have been working to prepare and plan for the beginning of Phase II of PASSE organized care. To ensure a smooth transition for the PASSEs, providers, and families, we believe a start date of March 1, 2019, is appropriate. This allows systems to be tested, ensures that the billing systems are functioning seamlessly to allow timely payments to providers, and provides more time for the training and enrolling of even more providers to the PASSE networks. 2) What will change for beneficiaries? Beneficiaries will continue to receive services in the same way they do today. Beneficiaries’ services will not be interrupted or affected by this additional time in transition to Phase II of the PASSE. Beneficiaries will continue to receive care coordination from the PASSEs. The PASSEs will become responsible for ensuring beneficiaries receive all services in their Person Centered Service Plan (PCSP) beginning March 1, 2019. 3) What will DHS do during that time? The extra time to transition allows both DHS and the PASSEs to keep providing beneficiaries, providers, and families with more information about the PASSE operation and answer questions. That includes: -Conducting webinars and town halls -Using client feedback to provide more informational materials -Educating and informing providers on the benefits of joining the PASSE system -Helping providers in enrolling in one or more PASSEs to be able to participate in the PASSE networks 4) Where can I find more information about the PASSE? Beneficiaries can find more information on our website passe.arkansas.gov. They can also call the PASSE Ombudsman at 501-320-6006. Providers with questions can call Tanya Giles at 501-501-320-6189.
Arkansas Medicaid
Provider Portal Application Required
Documents October 2018
2
Table of Contents Required Information and Documentation ..................................................................................................... 4
Document Specifications ............................................................................................................................... 5
Required Documents Tables ......................................................................................................................... 6
Physician Provider Types ........................................................................................................................................... 6 Physician Specialties .................................................................................................................................................. 6 ACS Waiver ................................................................................................................................................................ 8 AHEC/MCPG Group ................................................................................................................................................... 8 Alternatives for Adults with Physical Disabilities ...................................................................................................... 8 Ambulatory Surgical Center ...................................................................................................................................... 8 ARChoices .................................................................................................................................................................. 9 ARKids ........................................................................................................................................................................ 9 Autism ....................................................................................................................................................................... 9 Behavioral Health Agency ....................................................................................................................................... 10 Chiropractor ............................................................................................................................................................ 10 Dental ...................................................................................................................................................................... 11 Developmental Rehabilitation Services .................................................................................................................. 11 Division of Youth Services ....................................................................................................................................... 12 Domiciliary Care ...................................................................................................................................................... 12 Early Intervention / Adult Development ................................................................................................................. 12 Eligibility Only .......................................................................................................................................................... 13 Family Planning Clinic .............................................................................................................................................. 13 Federally Qualified Health Center ........................................................................................................................... 13 Health Department ................................................................................................................................................. 13 Hearing Services ...................................................................................................................................................... 14 Hemodialysis ........................................................................................................................................................... 14 Home Health ........................................................................................................................................................... 14 Hospice .................................................................................................................................................................... 14 Hyperalimentation .................................................................................................................................................. 14 Independent Choices Waiver .................................................................................................................................. 15 Independent Radiology ........................................................................................................................................... 15 Inpatient Psychiatric ................................................................................................................................................ 15 Independently Licensed Practitioners Group .......................................................................................................... 15 Independently Licensed Practitioners - Individual .................................................................................................. 16 Living Choices .......................................................................................................................................................... 16 Long Term Care ....................................................................................................................................................... 16 Medicare/Medicaid Crossover Only ........................................................................................................................ 17 Non Medicaid .......................................................................................................................................................... 17 Nurse Practitioner ................................................................................................................................................... 18 Optical Dispensing Contractor ................................................................................................................................ 18 Oral Surgeon ............................................................................................................................................................ 19 Nurse Widwife ......................................................................................................................................................... 19 Personal Care .......................................................................................................................................................... 19 Pharmacy ................................................................................................................................................................. 20 Podiatry ................................................................................................................................................................... 20 Private Duty Nursing ............................................................................................................................................... 20 Programs of All Inclusive Care for the Elderly ......................................................................................................... 21
3
Prosthetics (DME) .................................................................................................................................................... 21 Qualified Health Plan / Private Option Plan ............................................................................................................ 21 Registered Non Credentialed .................................................................................................................................. 21 Rehabilitation Hospital ............................................................................................................................................ 22 Rural Health ............................................................................................................................................................. 22 School Based ........................................................................................................................................................... 22 School District Personal Care .................................................................................................................................. 23 Target Case Management ....................................................................................................................................... 23 Therapy .................................................................................................................................................................... 24 Transportation ......................................................................................................................................................... 25 Vision ....................................................................................................................................................................... 25
4
Required Information and Documentation
During the process of completing your application to become an Arkansas Medicaid Provider, you will be
asked to supply quite a bit of information about yourself or your provider group. You will also need to
submit documentation specific to you or your group. To streamline your application process it is best if you
gather all the required information and documentation prior to beginning the application process.
Applications are divided into groups called Enrollment Types. Enrollment types are based on if the
applicant will be practicing as an individual or as part of a group, or if the provider is atypical. Providers are
grouped by “Provider Type”. This refers to the type of services provided. Examples of provider types are
Physicians, Long Term Care, Nurse Practitioner, or Oral Surgeon. Providers are further grouped by
“Provider Specialties”. Some provider types have only one provider specialty, others have many. The
“Physician” provider type has by far the most provider specialties.
Each provider type has an assigned two-digit code. In this document, this is referred to as the Provider
Type Code. Provider specialties also have an assigned two-digit code called the Provider Category.
Once you have identified your provider type and provider specialty, you can use the Required Documents
tables to identify your Enrollment Type options, Provider Type Code, Provider Category and all of the
documents you are required to submit with your application.
In the Required Documents tables, if the field says “Yes”, the document is required. If the field says “No”,
the document is not needed. If the field says “Opt”, it is optional for you to submit the document. Some
provider types/provider specialties may list specific agencies under License and/or Certification. If a specific
agency is listed, the license/certification must be supplied by that agency.
Some documents have special requirements such as specific signatures, dates or formats. Be sure to
verify that your documents meet all the requirements listed in the Document Specifications table below.
Once you have completed all of your documents, you will need to scan each document individually to your
computer to create a separate digital copy. You will upload each of these digital copies in the Attachments
Section of the online application process.
Prior to starting your application on the Provider Portal, be sure to:
Have electronic copies of all Required Documents
Know the following information
o Enrollment Type
o Provider Type Code (based on the type of services you provide)
o Provider Category Code (based on your specialty)
o National Provider Identifier
o Taxonomy Codes
o Tax ID - either Employer Identification Number or Social Security Number
o License Number
5
Document Specifications
Document Description
ACA Fee Payment required for all high risk provider groups. This is a non-refundable application processing fee
mandated by the Affordable Care Act. This fee must be paid online when completing the application. If you
have already paid the ACA Fee to another agency such as Medicare or another state Medicaid, you can
have your fee waived for Arkansas Medicaid. To receive the waiver, you will need to submit a letter, signed
by the applicant, attesting that your fee has already been paid and to whom the fee was paid.
In order to waive the fee, your letter must be scanned and uploaded to the online application.
Certification
(Cert)
Current certification from the certifying board. May vary based on type/specialty. Some types/specialties list
specific certifying agencies.
Must be scanned and uploaded to the online application.
Contract Agreement to participate in Medicaid is required for all providers. Must include:
Arkansas Medicaid Contract (DMS 653)
Ownership and Conviction Form (DMS 675)
Discloser of Significant Business Transactions Form (DMS 689)
Electronic Funds Transfer (EFT) (Automatic Deposit) Form
DMS Forms 653, 675, 689 and the EFT Form are part of the electronic application and can be
electronically signed and dated via the online application.
EPSDT
Agreement
EPSDT Agreement Form (DMS 831) must be signed and dated.
Must be scanned and uploaded to the online application.
Fingerprints Federal fingerprint-based background checks are required for all high risk providers (and their owners who
have a 5% or greater direct or indirect ownership interest). Contact one of the below vendors to process
electronic fingerprinting.
- Arkansas Live Scan - Hixson Adventure - Fitness & Tactical Academy
Fingerprints cannot be submitted on the online application. Follow instructions provided by the
vendor to process your fingerprints.
IRS Letter Group applicants must provide an IRS letter for each Tax ID number included in the application.
Must be scanned and uploaded to the online application.
License Current license from the professional licensing board. May vary by type/specialty. Some types/specialties
list specific license types. Name on license must perfectly match all other documentation.
Must be scanned and uploaded to the online application.
Medicare Some providers must also be enrolled in Medicare to enroll in Medicaid. No document required, but
Medicare enrollment must be completed first.
PCP Required Managed Care Primary Care Physician Agreement Form (DMS 2608). A maximum of 20 counties may be
selected. Must be signed and dated.
Must be scanned and uploaded to the online application.
Voided Check
or Bank Letter
To complete the Electronic Funds Transfer (EFT) enrollment, provide a voided check for the account listed
for EFT. The name on the check must match the name on the application. If a check that matches the
applicant is not available, substitute a letter from the bank that lists the account number on the EFT request
and the name of the applicant as an authorized user for that account.
Must be scanned and uploaded to the online application.
W9 Request for Taxpayer Identification Number and Certification (W9). Must include:
Provider Name (middle name must be initial only) which must match the name on the application
Address
Social Security Number (Individual Provider) or Tax ID Number (Provider Group)
Signature with Date
Must be scanned and uploaded to the online application.
Required Documents Tables
Physician Provider Types Enrollment Type Provider Type Code Provider Category IRS Letter
Voided Check / Bank Letter
Physician (Solo Practitioner) Individual or Individual within Group
01
Choose from Physician Specialties List
No Yes
Physician Group Group 02 Yes Yes
Physician DO (Solo Practitioner) Individual or Individual within Group
03 No Yes
Physician DO Group Group 04 Yes Yes
AHEC PCP Group Group 69 Yes Yes
Physician Specialties Provider Type Code Provider Category C
on
trac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
PC
P
Req
uir
ed
Adolescent Medicine
Choose from Physician Provider Types List
AA Yes Yes Yes No No No No No No
Allergy Immunology 03 Yes Yes Yes No No Yes No No No
Anesthesiology 05 Yes Yes Yes No No Yes No No No
CRNA C3 Yes Yes Yes Yes No Yes No No No
Emergency Medicine E1 Yes Yes Yes No No Yes No No No
General Practice 01 Yes Yes Yes No Yes Yes No No *
*PCP required for in-state unless a hospitalist. Optional for Memphis. AREA Health Education Centers (FQHC), Medical Physicians Groups, Hospitals, and Emergency Department Physicians, are not required to enroll as a Medicaid PCP. If you do not want to be a PCP, then the zero caseload form is required.
Geriatrics
Choose from Physician Provider Types List
38 Yes Yes Yes No No Yes No No No
Cardiovascular Disease 06 Yes Yes Yes No No Yes No No No
Dermatology 07 Yes Yes Yes No No Yes No No No
Endocrinology E2 Yes Yes Yes No No Yes No No No
Family Practice 08 Yes Yes Yes No Yes Yes No No *
*PCP required for in-state unless a hospitalist. Optional for Memphis.
Fluoride Varnish Certification
Choose from Physician Provider Types List
FC Yes Yes Yes Yes No Yes Yes No Yes
Gastroenterology 10 Yes Yes Yes No No Yes No No No
Gynecology/Obstetrics 16 Yes Yes Yes No Opt Yes No No Opt
Hematology H2 Yes Yes Yes No No Yes No No No
Infectious Diseases 55 Yes Yes Yes No No Yes No No No
Internal Medicine 11 Yes Yes Yes No Opt Yes No No *
*PCP required for in-state unless a hospitalist. Optional for Memphis. Hospitalist letter must be signed by the provider and the group manager. AREA Health Education Centers (FQHC), Medical Physicians Groups, Hospitals, and Emergency Department Physicians, are not required to enroll as a Medicaid PCP. If you do not want to be a PCP, then the zero caseload form is required.
Laryngology Choose from Physician Provider Types List
L1 Yes Yes Yes No No Yes No No No
Neonatology N1 Yes Yes Yes No No Yes No No No
7
Physician Specialties Provider Type Code Provider Category C
on
tra
ct
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
PC
P
Req
uir
ed
Nephrology 39 Yes Yes Yes No No Yes No No No
Neurology 13 Yes Yes Yes No No Yes No No No
Oncology
Choose from Physician Provider Types List
X1 Yes Yes Yes No No Yes No No No
Ophthalmology 18 Yes Yes Yes No No Yes No No No
Orthopedic X6 Yes Yes Yes No No Yes No No No
Osteopathy Manipulative Therapy 12 Yes Yes Yes No No Yes No No No
Osteopathy Radiation Therapy X7 Yes Yes Yes No No Yes No No No
Otology
Choose from Physician Provider Types List
X8 Yes Yes Yes No No Yes No No No
Otorhinolaryngology X9 Yes Yes Yes No No Yes No No No
Pathology 22 Yes Yes Yes No No Yes No No No
Pediatrics 37 Yes Yes Yes No Yes No No No *
*Required for in-state and optional for trade cities.
Physical Medicine
Choose from Physician Provider Types List
P3 Yes Yes Yes No No Yes No No No
Proctology 28 Yes Yes Yes No No Yes No No No
Psychiatry 26 Yes Yes Yes No No Yes No No No
Psychiatry Child P5 Yes Yes Yes No No No No No No
Pulmonary Disease 29 Yes Yes Yes No No Yes No No No
Radiology Diagnostic
Choose from Physician Provider Types List
30 Yes Yes Yes No No Yes No No No
Radiology Therapeutic 31 Yes Yes Yes No No Yes No No No
Rheumatology R4 Yes Yes Yes No No Yes No No No
Surgery Cardio S1 Yes Yes Yes No No Yes No No No
Surgery, Colon & Rectal S2 Yes Yes Yes No No Yes No No No
Surgery, General
Choose from Physician Provider Types List
02 Yes Yes Yes No No Yes No No No
Surgery, Neurological 14 Yes Yes Yes No No Yes No No No
Surgery, Orthopedic 20 Yes Yes Yes No No Yes No No No
Surgery, Pediatric 53 Yes Yes Yes No No No No No No
Surgery, Oncology 54 Yes Yes Yes No No Yes No No No
Surgery, Plastic & Reconstructive
Choose from Physician Provider Types List
24 Yes Yes Yes No No Yes No No No
Surgery, Thoracic 33 Yes Yes Yes No No Yes No No No
Surgery, Vascular S4 Yes Yes Yes No No Yes No No No
Urology 34 Yes Yes Yes No No Yes No No No
EPSDT E3 Yes Yes Yes No No No No No No
8
ACS Waiver Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Case Management Services Atypical 74 HC Yes Yes No DPSQA No No Yes Yes
Required f
or
Gro
ups o
nly
No Yes
Consultation Atypical 71 H9 Yes Yes No DPSQA No No Yes Yes No Yes
Crisis Intervention Atypical 85 HG Yes Yes No DPSQA No No Yes Yes No Yes
Environmental Modifications / Physical Adaptations
Atypical 72 HA Yes Yes No DPSQA No No Yes Yes No Yes
Organized Healthcare Delivery System
Atypical 82 HF Yes Yes No DPSQA No No Yes No No Yes
Specialized Medical Supplies Atypical 73 HB Yes Yes No DPSQA No No Yes Yes No Yes
Supported Employment Atypical 75 HE Yes Yes No DPSQA No No Yes Yes No Yes
Supported Living Atypical 67 H7 Yes Yes No DPSQA No No Yes Yes No Yes
TCM ages 0-20 Group 76 C6 Yes Yes No DPSQA No No Yes No No Yes
AHEC/MCPG Group Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Adolescent Medicine Group 81 AA Yes Yes No No No No No No Yes No Yes
Family Practice Group 81 08 Yes Yes No No No Yes No No Yes Yes Yes
Internal Medicine Group 81 11 Yes Yes No No No Yes No No Yes Yes Yes
Alternatives for
Adults with Physical
Disabilities Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Environmental Adaptations Atypical 84 A8 Yes Yes No DAAS No No Yes Yes * No Yes
* IRS Letter required for Groups only.
Ambulatory Surgical
Center Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Ambulatory Surgical Center Group 28 A4 Yes Yes Yes No No Yes Yes No Yes No Yes
9
ARChoices Enrollment Type Pro
vid
er
Typ
e
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P R
eq
uir
ed
Vo
ide
d C
hec
k
/ B
an
k L
ett
er
Adult Day Care Atypical 55 E9 Yes Yes No DAAS No No Yes Yes
Required f
or
Gro
ups o
nly
No Yes
Adult Day Health Care Atypical 56 EA Yes Yes No DAAS No No Yes Yes No Yes
Adult Foster Care Atypical, Individual or Group
51 E5 Yes Yes No DAAS No No Yes Yes No Yes
Agency Attendant Care Atypical 97 AC Yes Yes No DAAS No No Yes Yes No Yes
Counseling Case Management Atypical 98 CC Yes Yes No DAAS No No Yes Yes No Yes
Frozen Home Delivered Meals Atypical 53 EC Yes Yes No DAAS No No Yes Yes No Yes
Home Delivered Meals Atypical 53 E7 Yes Yes No DAAS No No Yes Yes No Yes
Personal Emergency Response Systems
Atypical 54 E8 Yes Yes No DAAS No No Yes Yes No Yes
Respite Atypical 57 EB Yes Yes No DAAS No No Yes Yes No Yes
Traditional Attendant Care Atypical 97 AT Yes Yes No DAAS No No Yes Yes No Yes
ARKids Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
School District Outreach Group 92 SO Yes Yes LEA # No No No Yes No Yes No Yes
Autism Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Clinical Services Specialist (group only)
Atypical, Individual within a Group or Group
06 AZ Yes Yes No UAMS Partners
No No Yes No
Required f
or
Gro
ups o
nly
No Yes
Consultants Atypical, Individual within a Group or Group
06 AW Yes Yes No No No No No No No Yes
Intensive Intervention (group only) Atypical, Individual within a Group or Group
06 AV Yes Yes No UAMS Partners
No No Yes No No Yes
Lead/Line Therapist Atypical, Individual within a Group or Group
06 AX Yes Yes No No No No No No No Yes
10
Behavioral Health
Agency Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Behavioral Health Agency Group 26 R6 Yes Yes No Yes No Opt Yes No Yes No Yes
Independently Licensed Clinicians (LPC, LCSW, LMFT)
Individual 19 NC Yes Yes Yes No No Opt No No No No Yes
Independently Licensed Clinicians (Licensed Psychologist and Licensed Psychological Examiner Independent (LPE-I))
Individual 19 XX Yes Yes Yes No No Opt No No No No Yes
Non-Independently Licensed Clinicians
Atypical 95 NW No Yes Yes No No Opt No No No No No
Qualified Beharioral Health Provider (QBHP)
Atypical 95 NT No Yes No No No No No No No No No
Chiropractor Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Chiropractor Individual, Individual within a Group or Group
18 35 Yes Yes Yes No No Yes No No
Gro
ups
only
No Yes
11
Dental Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Dental Individual or Individual within a Group
08 V2 Yes Yes Yes No Opt No No No
Required f
or
Gro
ups o
nly
No Yes
EPSDT Individual or Individual within a Group
08 E3 Yes Yes No No Yes No No No No Yes
Fluoride Varnish Individual or Individual within a Group
08 FC Yes Yes Yes No No No No No No Yes
Mobile Dental Facility Individual or Individual within a Group
08 V0 Yes Yes Yes No Opt No No No No Yes
Orthodontia Individual or Individual within a Group
08 V6 Yes Yes Yes No Opt No No No No Yes
Dental Group Group 31 V2 Yes Yes No No Yes No No No Yes No Yes
EPSDT Group Group 31 E3 Yes Yes No No Yes No No No Yes No Yes
Mobile Dental Facilities Group (section 4 required)
Group 31 V0 Yes Yes No No Yes No No No Yes No Yes
Orthodontia Group Group 31 V6 Yes Yes No No Yes No No No Yes No Yes
Developmental
Rehabilitation
Services Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Developmental Rehab Services Individual or Group 78 DR Yes Yes No Early Intervention
No Yes Yes No
Gro
ups
only
No Yes
12
Division of Youth
Services Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
DCFS Rehab Services Group Group 88 RJ Yes Yes No No No No Yes No Yes No Yes
DCFS Rehab Services Group Group 88 RL Yes Yes No No No No Yes No Yes No Yes
DCFS Rehab Services Performing
Individual or Individual within a Group
89 RJ Yes Yes No No No No Yes No
Gro
ups
only
No Yes
DYS Rehab Services Performing Individual or Individual within a Group
89 RL Yes Yes No No No No Yes No
Gro
ups
only
No Yes
DYS/TCM Group Group 88 CN Yes Yes No No No No Yes No Yes No Yes
DYS/TCM Performing Individual or Individual within a Group
89 CO Yes Yes No No No No Yes No
Gro
ups
only
No Yes
Domiciliary Care Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Domiciliary Care (must include cost statement with app)
Atypical 36 V5 Yes Yes No No No No Yes No
Gro
ups
only
No Yes
Early Intervention /
Adult Development Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
ADDT-Adult Developmental Day Treatment
Group 24 AN Yes Yes No DPSQA No No Yes No Yes No Yes
AMC-Early Intervention Day Treatment
Group 24 AM Yes Yes No DPSQA No No Yes No Yes No Yes
Developmental Day Treatment Center
Group 24 V3 Yes Yes No DPSQA No No Yes No Yes No Yes
EIDT-Early Intervention Day Treatment
Group 24 AO Yes Yes No DPSQA No No Yes No Yes No Yes
13
Eligibility Only Enrollment Type Pro
vid
er
Typ
e
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P R
eq
uir
ed
Vo
ide
d C
hec
k /
Ban
k L
ett
er
Eligibility Only Atypical 70 H8 Yes Yes No No No No Yes No * No Yes
* IRS Letter required for Groups only.
Family Planning
Clinic Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Family Planning Group 35 FI Yes Yes Yes Yes No Yes Yes No Yes Yes Yes
Federally Qualified
Health Center Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
FQHC Group 49 F2 Yes Yes Yes HRSA Grant Yes No Yes No Yes No Yes
EPSDT Group 49 E3 Yes Yes Yes Yes Yes No Yes No Yes Yes Yes
Must enroll with both specialties and be located in AR.
Health Department Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Cancer Screening Group 30 C1 Yes Yes Yes No No Yes No No Yes No Yes
Cancer Treatment Group 30 C2 Yes Yes Yes No No Yes No No Yes No Yes
Communicable Diseases Group 30 C8 Yes Yes Yes No No Yes No No Yes No Yes
Dental Clinic Group 30 VI Yes Yes Yes No No Yes No No Yes No Yes
EPSDT Group 30 E3 Yes Yes Yes No Yes Yes No No Yes No Yes
Immunizations Group 30 V8 Yes Yes Yes No No Yes No No Yes No Yes
Maternity Clinic Group 30 MI Yes Yes Yes No No Yes No No Yes No Yes
Tuberculosis Group 30 TH Yes Yes Yes No No Yes No No Yes No Yes
14
Hearing Services Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Audiology (section 4 required) Individual, Individual within a Group or Group
20 64 Yes Yes Yes No No No No No
Gro
ups
only
No Yes
Hearing Aid Dealer Group 66 H1 Yes Yes Yes No No Yes Yes No Yes No Yes
Hemodialysis Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Hemodialysis Group 34 H5 Yes Yes Yes No No Yes Yes No Yes No Yes
Home Health Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Home Health Group 14 H3 Yes Yes Class A No No Yes Yes No Yes No Yes
Hospice Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Hospice Group 47 H6 Yes Yes Yes No No Yes Yes No Yes No Yes
Hospice Group Group 64 H6 Yes Yes No No No Yes No No Yes No Yes
Hyperalimentation Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Enteral Nutrition Group 33 HN Yes Yes Yes No No Yes Yes No Yes No Yes
Parental Nutrition Group 33 H4 Yes Yes Pharmacy No No Yes Yes No Yes No Yes
15
Independent Choices
Waiver Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Independent Choice Atypical 87 IC Yes Yes No No No No Yes Yes * No Yes
* IRS Letter required for Groups only.
Independent
Radiology Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Independent X-Ray Group 10 RA Yes Yes No Yes No Yes Yes No Yes No Yes
Portable X-Ray Group 10 63 Yes Yes No Yes No Yes Yes No Yes No Yes
Radiation Therapy-Complete Group 10 R9 Yes Yes No Yes No Yes Yes No Yes No Yes
Inpatient Psychiatric Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Inpatient Psychiatric Under 21 (may stand alone)
Group 25 W3 Yes Yes Yes Yes No Yes Yes No Yes No Yes
Psychiatric Facility Inpatient Group 25 WA Yes Yes Yes JACHO, COA or CARF
No * Yes No Yes No Yes
Residential Treatment Facility Group 25 WB Yes Yes Yes JACHO, COA or CARF
No Yes Yes No Yes No Yes
Sexual Offender Group 25 WC Yes Yes Yes No No No No No Yes No Yes
*If the Residential Treatment Unit is within a Psychiatric Hospital, the W3 specialty and Medicare is required also.
Independently
Licensed
Practitioners Group Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Licensed Clinical Social Worker Group 44 WI Yes Yes No No No Opt No No Yes No Yes
Licensed Marriage & Family Therapist
Group 44 R5 Yes Yes No No No Opt No No Yes No Yes
Licensed Professional Counselor Group 44 W2 Yes Yes No No No Opt No No Yes No Yes
Psychology Licensed Psychological Examiner - Independent
Group 44 62 Yes Yes No No No Opt No No Yes No Yes
16
Independently
Licensed
Practitioners -
Individual Enrollment Type Pro
vid
er
Typ
e
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P R
eq
uir
ed
Vo
ide
d C
hec
k /
Ban
k L
ett
er
Licensed Marriage & Family Therapist
Individual or Individual within a Group
19 R5 Yes Yes Yes DPSQA No Opt No No
Required f
or
Gro
ups o
nly
No Yes
Licensed Professional Counselor Individual or Individual within a Group
19 W2 Yes Yes Yes DPSQA No Opt No No No Yes
Licensed Clinical Social Worker Individual or Individual within a Group
19 WI Yes Yes Yes DPSQA No Opt No No No Yes
Licensed Psychological Examiner – Independent (LPE-I)
Individual or Individual within a Group
19 62 Yes Yes Yes DPSQA No No No No No Yes
Psychology Individual or Individual within a Group
19 62 Yes Yes Yes DPSQA No Opt No No No Yes
Living Choices Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Assisted Living Agency Group 94 AH Yes Yes Class A Home Health
No No No Yes Yes Yes No Yes
Assisted Living Facility Group 94 AL Yes Yes Level 2 ALF No No No Yes Yes Yes No Yes
Assisted Living Pharmacist Consultant
Group 94 AP Yes Yes AR Pharmacy Board
No No No Yes Yes Yes No Yes
Long Term Care Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Easter Seals Group 13 WO Yes Yes Yes No No Yes Yes No Yes No Yes
ICF/Infant Infirmaries Group 13 W9 Yes Yes Yes No No Yes Yes No Yes No Yes
Intermediate Care Facility Mentally Retarded
Group 13 W5 Yes Yes Yes No No Yes Yes No Yes No Yes
Skilled Nursing Facility Group 11 S5 Yes Yes OLTC No No Opt Yes No Yes No Yes
Special Services Group 11 W8 Yes Yes Yes No No Yes Yes No Yes No Yes
17
Medicare/Medicaid
Crossover Only Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Crossover Only Group 41 M4 Yes Yes No No No Yes Yes No Yes No Yes
Non Medicaid Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
DDS Non Medicaid Atypical 86 N5 Yes Yes No No No No No No * No Yes
* IRS Letter required for Groups only.
18
Nurse Practitioner Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Acute Care Individual or Individual within a Group
58 N9 Yes Yes Yes Yes Opt Opt No No
Required f
or
Gro
ups o
nly
No Yes
EPSDT Individual or Individual within a Group
58 E3 Yes Yes Yes Yes Yes Yes No No No Yes
Family Nurse Individual or Individual within a Group
58 N6 Yes Yes Yes Yes Opt Opt No No No Yes
Gerontological Individual or Individual within a Group
58 N7 Yes Yes Yes Yes Opt Opt No No No Yes
OB/GYN Individual or Individual within a Group
58 N4 Yes Yes Yes Yes Opt Opt No No No Yes
Other Individual or Individual within a Group
58 N0 Yes Yes Yes No Opt Opt No No No Yes
Pediatric Nurse Individual or Individual within a Group
58 N3 Yes Yes Yes Yes Opt Opt No No No Yes
Psychiatric/Mental Health Individual or Individual within a Group
58 N8 Yes Yes Yes Yes Opt Opt No No No Yes
Acute Care Group Group 62 N9 Yes Yes No No No Opt No No Yes No Yes
Family Nurse Group Group 62 N6 Yes Yes No No No Opt No No Yes No Yes
Gerontological Services Group Group 62 N7 Yes Yes No No No Opt No No Yes No Yes
OB/GYN Group Group 62 N4 Yes Yes No No No Opt No No Yes No Yes
Pediatric Nurse Group Group 62 N3 Yes Yes No No No Opt No No Yes No Yes
Psychiatric/Mental Health Group Group 62 N8 Yes Yes No No No Opt No No Yes No Yes
Other Group Group 62 N0 Yes Yes No No No Opt No No Yes No Yes
Optical Dispensing
Contractor Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Optical Dispensing Contractor Atypical 23 X2 Yes Yes Yes Yes No Yes Yes No * No Yes
* IRS Letter required for Groups only.
19
Oral Surgeon Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Oral Surgeon Group Group 80 X5 Yes Yes No No No No No No Yes No Yes
Oral Surgeon Individual Individual or Individual within a Group
79 X5 Yes Yes lic & DEA No No No No No
Gro
ups
only
No Yes
Nurse Widwife Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Nurse Midwife Individual, Individual within a Group or Group
99 N2 Yes Yes Yes No No Opt No No
Gro
ups
only
No Yes
Personal Care Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Area Agency on Aging only Atypical 32 PA Yes Yes Yes No No No Yes Yes
Required f
or
Gro
ups o
nly
No Yes
DDS Atypical 32 PD Yes Yes ACS or Center Based
No No No Yes Yes No Yes
Level 1 ALF Atypical 32 PG Yes Yes OLTC No No No Yes Yes No Yes
Level 2 ALF Atypical 32 PH Yes Yes OLTC No No No Yes Yes No Yes
Private Care Agency* or Health Agency
Atypical 32 P1 Yes Yes Yes No No No Yes Yes No Yes
Residential Care Facility Atypical 32 R3 Yes Yes Yes No No No Yes Yes No Yes
Weekend Atypical 32 PE Yes Yes Yes No No No Yes Yes No Yes
*Private Care Agency license must also have a minimum of $1 million liability insurance policy, & be enrolled as an AR Choices provider.
20
Pharmacy Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Pharmacy Group 07 P2 Yes Yes Yes No No No Yes No Yes No Yes
Pharmacy, Administers Vaccines Group 07 PV Yes Yes Yes No No No Yes No Yes No Yes
Pharmacy, Anti-Hemophilic Group 07 P9 Yes Yes Yes No No No Yes No Yes No Yes
Pharmacy, Chain Group 07 PC Yes Yes Yes No No No Yes No Yes No Yes
Pharmacy, Compounding Group 07 PM Yes Yes Yes No No No Yes No Yes No Yes
Pharmacy, Home Infusion Group 07 PN Yes Yes Yes No No No Yes No Yes No Yes
Pharmacy, Long Term Care/Closed Door
Group 07 PR Yes Yes Yes No No No Yes No Yes No Yes
All Pharmacies require DEA. The physical address on the DEA must match the physical address on the application. AR does not enroll mail order pharmacies unless they are trying to bill for a drug that is not available in AR and they have prior approval from the state Pharmacy unit. Non bordering pharmacies must have claim with their application.
Podiatry Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Podiatry Group 48 48 Yes Yes Yes No No Yes Yes No Yes No Yes
Podiatry Individual Individual or Individual within a Group
17 48 Yes Yes Yes No No Yes No No
Gro
ups
only
No Yes
Private Duty Nursing Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Private Duty Nursing Group 38 P6 Yes Yes Extended Care Services
No No No Yes No Yes No Yes
Private Duty Nursing for School District
Group 38 PF Yes Yes LEA # No No No Yes No Yes No Yes
21
Programs of All
Inclusive Care for
the Elderly Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
PACE Group 93 PJ Yes Yes DAAS Adult Day Health Care
DAAS No Yes Yes No Yes No Yes
A three way agreement signed by DAAS, CMS, and the provider also required.
Prosthetics (DME) Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Durable Medical Equipment Group 16 V4 Yes Yes No Accred. No Yes Yes No Yes No Yes
Orthotic/Appliances Group 16 Z1 Yes Yes No Accred. No Yes Yes No Yes No Yes
Prosthetic Devices Group 16 P4 Yes Yes No Accred. No Yes Yes No Yes No Yes
Qualified Health Plan
/ Private Option Plan Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Qualified Health Plan Carries Group 27 A3 No Yes No No No No No No Yes No Yes
Managed Care Dental Group 27 AB No Yes No No No No No No Yes No Yes
Registered Non
Credentialed Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Non Credentialed Atypical 95 NT No No No No No No No No
Gro
ups
only
No No
Physician Assistant Atypical 95 NV No Yes No No No No No No No No
Residents Atypical 95 NU No No No No No No No No No No
22
Rehabilitation
Hospital Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
EPSDT Group 26 E3 Yes Yes Yes No No Yes Yes No Yes No Yes
Rehabilitation Hospital Group 26 RI Yes Yes Yes No Yes Yes Yes No Yes No Yes
Rehabilitative Services for the Developmentally Disabled
Group 26 R5 Yes Yes No No No Yes Yes No Yes No Yes
RSPD/Residential Rehab Center Group 26 RC Yes Yes No CARF or JACHO
No Yes Yes No Yes No Yes
Rural Health Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
EPSDT Group 29 E3 Yes Yes No No Yes Yes Yes No Yes No Yes
Rural Health Group 29 R2 Yes Yes No No Yes Yes Yes No Yes No Yes
Rural Health Independent Free Standing
Group 29 R8 Yes Yes No No Yes Yes Yes No Yes No Yes
School Based Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
School Based Audiology Individual, Individual within a Group or Group
20 SB Yes Yes LEA# No No No No No
Gro
ups
only
No Yes
School Based Child Health Services
Group 45 S7 Yes Yes No No Yes No Yes No Yes No Yes
School Based Child Health Services EPSDT
Group 45 E3 Yes Yes No No Yes No Yes No Yes No Yes
School Based Child Services EPSDT
Group 61 E3 Yes Yes Yes No Yes No Yes No Yes No Yes
School Based Hearing Group 59 S8 Yes Yes LEA# No No No Yes No Yes No Yes
School Based Mental Health Group 91 VV Yes Yes LEA# No No No Yes No Yes No Yes
School Based Vision Group 60 S9 Yes Yes LEA# No No No Yes No Yes No Yes
School Based Vision and Hearing Group 61 SA Yes Yes LEA# No No No Yes No Yes No Yes
23
School District
Personal Care Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
School District only Atypical 32 PS Yes Yes LEA# No No No Yes Yes * No Yes
* IRS Letter required for Groups only.
Target Case
Management Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Targeted Case Management Individual, Individual within a Group or Group
46 C6 & CM
Yes Yes Yes No No No Yes Yes
Gro
ups
only
No Yes
TCM DDS Group Group 63 CM Yes Yes No DDS No No Yes Yes Yes No Yes
TCM Group ages 0-20 Group 63 C6 Yes Yes No No No No Yes Yes Yes No Yes
TCM Group ages 21-59 Group 65 C7 Yes Yes No DAAS No No Yes Yes Yes No Yes
TCM Group ages 60 and older Group 65 C5 Yes Yes No DAAS No No Yes Yes Yes No Yes
24
Therapy Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
EPDST (optional) Individual or Individual within a Group
21 E3 No No No No Yes No No No No No Yes
Occupational Therapist Individual or Individual within a Group
21 T6 Yes Yes Yes NBCOT or Letter
Opt No No No No No Yes
Occupational Therapist Assistant Individual or Individual within a Group
21 TO Yes Yes Yes No Opt No No No No No Yes
Occupational Therapy for School Districts
Group 43 T6 Yes Yes Yes No Yes No No No Yes No Yes
Occupational Therapy Group Group 42 T6 Yes Yes Yes No No No No No Yes No Yes
Physical Therapist Individual or Individual within a Group
21 T1 Yes Yes Yes No Opt No No No No No Yes
Physical Therapist Assistant Individual or Individual within a Group
21 TP Yes Yes Yes No Opt No No No No No Yes
Physical Therapy for School Districts
Group 43 T1 Yes Yes Yes No Yes No No No Yes No Yes
Physical Therapy Group Group 42 T1 Yes Yes Yes No No No No No Yes No Yes
Speech Pathologist Individual or Individual within a Group
21 T2* Yes Yes Yes ASHA or CFY Opt No No No No No Yes
Speech Pathologist Assistant Individual or Individual within a Group
21 TS Yes Yes Yes No Opt No No No No No Yes
Speech Therapy for School Districts
Group 43 T2 Yes Yes Yes No Yes No No No Yes No Yes
Speech Therapy Group Group 42 T2 Yes Yes Yes No No No No No Yes No Yes
*For specialty T2, submit a letter from the Board that verifies that you can perform services in lue of a license from the AR Board of Speech Examiners Speech Language Pathology and Audiology. Submit a Clinical Fellowship Year plan in lue of an ASHA certification.
25
Transportation Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
Ambulance, Advanced Life Support with EKG
Group 15 A6 Yes Yes Yes No No Yes Yes No Yes No Yes
Ambulance, Advanced Life Support without EKG
Group 15 A7 Yes Yes Yes No No Yes Yes No Yes No Yes
Ambulance, Air Fixed Wing Group 15 TB Yes Yes Yes No No Yes Yes No Yes No Yes
Ambulance, Air Helicopter Group 15 TA Yes Yes Yes No No Yes Yes No Yes No Yes
Ambulance, Emergency Group 15 A1 Yes Yes Yes No No Yes Yes No Yes No Yes
Ambulance, Non-Emergency Group 15 A2 Yes Yes Yes No No Yes Yes No Yes No Yes
NET Transportation Broker Atypical 15 TD Yes Yes No Yes No No Yes No
Gro
ups
only
No Yes
Non Public Transportation Atypical 15 TC Yes Yes No DPSQA No No Yes No No Yes
Vision Enrollment Type Pro
vid
er
Ty
pe
Co
de
Pro
vid
er
Cate
go
ry
Co
ntr
ac
t
W9
Lic
en
se
Cert
EP
SD
T
Me
dic
are
AC
A F
ee
Fin
ge
rpri
nts
IRS
Le
tte
r
PC
P
Req
uir
ed
Vo
ide
d
Ch
ec
k /
Ban
k L
ett
er
EPSDT Individual, Individual within a Group or Group
22 E3 Yes Yes No No Yes Yes No No
Required f
or
Gro
ups o
nly
No Yes
Ocularist (Crossover only) Individual, Individual within a Group or Group
22 X0 Yes Yes Yes No Yes Yes No No No Yes
Optician & Dispensary (Crossover only)
Individual, Individual within a Group or Group
22 X3 Yes Yes Yes No Yes Yes No No No Yes
Optometrist Individual, Individual within a Group or Group
22 X4 Yes Yes Yes No Yes Yes No No No Yes
170.100 Introduction 8-1-18
Arkansas Medicaid’s Primary Care Case Management (PCCM) Program operates statewide under the authority of the Medicaid State Plan. A. Most Medicaid beneficiaries and all ARKids First-B participants must enroll with a primary care physician
(PCP), also known as a primary care case manager (PCCM). 1. PCPs provide primary care services and health education. 2. PCPs make referrals for medically necessary specialty physician’s services, hospital care and other
services. 3. PCPs assist their enrollees with locating medical services. 4. PCPs coordinate and monitor their enrollees’ prescribed medical and rehabilitation services.
B. Medicaid enrollees may receive services only from their PCP unless their PCP refers them to another provider, or unless they access a service that does not require a PCP referral.
C. If a beneficiary does not have a primary care provider, Arkansas Medicaid will allow up to four (4) visits per state fiscal year without a Primary Care Physician (PCP) referral to a hospital affiliated Walk-in Clinic or Emergent Clinic.
D. These visits apply to all related benefit limits.
171.400 PCP Referrals 1-1-18
A. Referrals may be only for medically necessary services, supplies or equipment. B. Enrollee free choice by naming two or more providers of the same type or specialty. C. PCPs are not required to make retroactive referrals. D. Since PCPs are responsible for coordinating and monitoring all medical and rehabilitative services
received by their enrollees, they must accept co-responsibility for the ongoing care of patients they refer to other providers.
E. PCP referrals expire on the date specified by the PCP, upon receipt of the number or amount of services specified by the PCP or in six months, whichever occurs first. (This requirement varies somewhat in some programs; applicable regulations are clearly set forth in the appropriate Arkansas Medicaid Provider Manuals.)
F. There is no limit on the number of times a referral may be renewed, but renewals must be medically necessary and at least every six months (with exceptions as noted in part E, above).
G. An enrollee’s PCP determines whether it is necessary to see the enrollee before making or renewing a referral.
H. Medicaid beneficiaries and ARKids First-B participants are responsible for any charges they incur for services obtained without PCP referrals except for the services listed in Section 172.100.
I. Some services such as personal care require an Independent Assessment. Please refer to the Independent Assessment Guide for related information and referral processes.
171.410 PCCM Referrals and Documentation 7-1-05
A. Medicaid provides an optional referral form, form DMS-2610, to facilitate referrals. View or print form DMS-2610. 1. Additionally, PCP referrals may be oral, by note or by letter. 2. Referrals may be faxed.
B. Regardless of the means by which the PCP makes the referral, Medicaid requires documentation of the referral in the enrollee’s medical record. 1. Medicaid also requires documentation in the patient’s chart by the provider to whom the referral is
made. 2. Providers of referred services must correspond with the PCP to the extent necessary to coordinate
patient care and as requested by the PCP.
171.510 Access Requirements for PCPs 7-1-05
A. A PCP must have hours of operation that are reasonable and adequate to serve all of his or her patients. 1. The PCP’s office must be open to Medicaid enrollees during the same hours and for the same
number of hours as it is for self-pay and insured patients. 2. ConnectCare enrollees must have the same access as private pay and insured persons to
emergency and non-emergency medical services. B. A PCP must make available 24-hour, 7 days per week telephone access to a live voice (an employee of
the primary care physician or an answering service) or to an answering machine that will immediately page an on-call medical professional. The on-call professional will: 1. Provide information and instructions for treating emergency and non-emergency conditions, 2. Make appropriate referrals for non-emergency services, and 3. Provide information regarding accessing other services and handling medical problems during hours
the PCP’s office is closed. C. Response to after-hours calls regarding non-emergencies must be within 30 minutes.
1. PCPs must make the after-hours telephone number as widely available as possible to their patients. 2. When employing an answering machine with recorded instructions for after-hours callers, PCPs
should regularly check to ensure that the machine functions correctly and that the instructions are up to date.
D. PCPs in underserved and sparsely populated areas may refer their patients to the nearest facility available, but enrollees must be able to obtain the necessary instructions by telephone.
E. As regards access to services, PCPs are required to provide the same level of service for their ConnectCare enrollees as they provide for their insured and private-pay patients.
F. Physicians and facilities treating a PCP’s enrollees after hours must report diagnosis, treatment, significant findings, recommendations and any other pertinent information to the PCP for inclusion in the patient’s medical record.
G. A PCP may not refer ConnectCare enrollees to an emergency department for non-emergency conditions during the PCP’s regular office hours.
DIVISION OF MEDICAL SERVICES ARKANSAS MEDICAID PRIMARY CARE PHYSICIAN MANAGED CARE PROGRAM
REFERRAL FORM
Medicaid Provider Receiving Referral I have performed a clinical assessment of the patient named below, whom I am referring for:
Please advise me, as appropriate, of your medical findings and diagnosis, treatment plan and/or services you provide subsequent to this referral. Please note that services beyond the scope of this referral require a new referral. Referrals for ongoing services require renewal at least every 6 months. Medicaid Beneficiary Name Medicaid I.D. Number Primary Care Physician (PCP) Name PCP Provider ID Number/Taxonomy Code (Please print, stamp or type physician’s name) PCP Signature PCP Phone Number
Date DMS-2610 (Rev. 4/07)