Medical assistance program provider application




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DIVISION OF MEDICAL SERVICES

MEDICAL ASSISTANCE PROGRAM

PROVIDER APPLICATION

As a condition for entering into or renewing a provider agreement, all applicants must complete this provider application. A true, accurate and complete disclosure of all requested information is required by the Federal and State Regulations that govern the Medical Assistance Program. Failure of an applicant to submit the requested information or the submission of inaccurate or incomplete information may result in refusal by the Medical Assistance program to enter into, renew or continue a provider agreement with the applicant. Furthermore, the applicant is required by Federal and State Regulations to update the information submitted on the Provider Application.


Whenever changes in this information occur, please submit the change in writing to:
Medicaid Provider Enrollment Unit

Hewlett Packard Enterprise

P. O. Box 8105

Little Rock, AR 72203-8105
All dates, except where otherwise specified, should be written in the month/day/year (MMDDYY) format. Please print all information.
This information is divided into sections. The following describes which sections are to be completed by the applicant:

Section I - All providers

Section II - Facilities Only

Section III - Pharmacists/Registered Respiratory Therapist Only

Section IV - Provider Group Affiliations

Electronic Fund Transfer - All Providers (optional)

Managed Care Agreement - Primary Care Physician

W-9 Tax Form - All Providers

Contract - All Providers

Ownership and Conviction

Disclosure - All Providers

Disclosure of Significant

Business Transactions - All Providers

FOR OFFICE USE ONLY


Provider ID Number Pending

Taxonomy Code

Specialty Code Computer

Provider Type OK to Key

Keyed

Effective Date Maintenance Checked


SECTION I: ALL PROVIDERS

This section MUST be completed by all providers.

(1) Date of Application: Enter the current date in month/day/year format.
____ ____/____ ____/ ____ ____

MM DD Year


(2) Last Name, First Name, Middle Initial, and Title: Enter the legal name of the applicant. The title spaces are reserved for designations such as MD, DDS, CRNA or OD. If the space is insufficient, please abbreviate.
If entering any other name such as an organization, corporation or facility, enter the full name of the

entity in item 3. NOTE: Item 2 or 3 must be completed, BUT NOT BOTH.

Last Name First Name M. I. Title

(3) Group, Organization or Facility Name: Enter full name of the entity.

Examples: John R. Doe, PA; Adam B. Corn, Inc.; Arkansas Emer. Phys. Group; Pulaski County Hospital; John Thompson, M. D., DBA Thompson Clinic


________________________________________________________________________________

Corporation Name


________________________________________________________________________________

Fictitious Name (Doing Business As)



Must submit documentation that the above fictitious name is registered with the appropriate board within your state, (i.e., Secretary of State’s, County Clerk) of the county in which the corporation’s registered office is located.

(4) Application Type: Circle one of the following codes which coincide with fields 2 or 3. Each application type listed below will be required to complete Disclosure Forms (DMS-675 – Ownership and Conviction Disclosure and DMS-689 – Disclosure of Significant Business Transactions.)


*NOTE: IF THE FORMS ARE NOT COMPLETED AND ATTACHED, THE APPLICATION WILL BE DENIED.
0 = Individual Practitioner (i.e., physician, dentist, a licensed, registered or certified practitioner)

1 = Sole Proprietorship (This includes individually owned businesses.)

2 = Government Owned

3 = Business Corporation, for profit

4 = Business Corporation, non-profit * copy of Tax Form 501 (c) (3) must accompany this application

5 = Private, for profit

6 = Private, non-profit * copy of Tax Form 501 (c) (3) must accompany this application

7 = Partnership

8 = Trust

9 = Chain



* NOTE: IF THE TAX FORM IS NOT ATTACHED THE APPLICATION WILL BE DENIED

(5) SSN/FEIN Number: Enter the Social Security Number of the applicant or the Federal Employer Identification Number of the applicant. IF ENROLLING AN INDIVIDUAL APPLICANT THIS FIELD MUST REFLECT A SOCIAL SECURITY NUMBER.


____ _____ _____ - _____ _____ - _____ _____ _____ _____

Social Security Number



NOTE: If an individual has a Federal Employee Identification Number, you will need to complete two (2) applications and two (2) contracts. One (1) as an individual and one (1) as an organization.

____ _____ - _____ _____ _____ _____ _____ _____ _____

Federal Employee Identification Number

(6) National Provider Identification Number (NPI) and Taxonomy Code: Enter the National Provider Identification Number and the taxonomy code of the applicant.


_______________________________________________________

National Provider Identification Number


_______________________________________________________

Taxonomy Code


(7) Place of Service - Street Address


  1. Enter the applicant's service location address, include suite number if applicable. THIS FIELD

IS MANDATORY.
___________________________________________________________________________


  1. Enter any additional street address. (SHOULD REFLECT POST OFFICE BOX IF

UNDELIVERABLE TO A STREET ADDRESS)
___________________________________________________________________________
(C) City, State, Zip+4 Code - enter the applicant's city, state and zip+4 code. Use the Post Office's two letter abbreviation for State. Enter the complete nine digit zip code.

_______________

City State Zip Code+4

(D) Telephone Number - enter the area code and telephone number of the location in which the services are provided.
__________ _________________________

Area Code Telephone Number




  1. Fax Number – enter the area code and fax number of the location in which the services are

provided.

__________ _________________________

Area Code Fax Number

(8a) Billing Street Address: This is the billing address where your Medicaid checks, Remittance Statements (RA) and information will be sent. Use the same format as the place of service address, P. O. Box may be entered in billing address.



City State Zip Code+4


__________ _________________________

Area Code Telephone Number


__________ _________________________

Area Code Fax Number


(8b) Provider Manuals and Updates: Please review Section I sub-section 101.000; 101.200; and 101.300 in your Arkansas Medicaid provider manual regarding provider manuals and updates. Providers will receive emails notifying them of applicable manual updates, official notices, notices of rule making and provider memos that are available on the Arkansas Medicaid website (www.medicaid.state.ar.us). The website is updated weekly.


Email address:
When providing your email address, please do the following:

  • Please ensure your email address is legible.

  • Use a generic email address that more than one person can access (e.g., xyzclinic@yahoo.com instead of janedoe@yahoo.com). Email addresses often become outdated when an individual leaves a practice or clinic.

  • Make sure the email address will accept email from hpe.com. You may have to instruct your network administrator or email provider to accept emails from hpe.com. Arkansas Medicaid sends email in bulk and some email services block bulk email unless instructed otherwise.

If Internet access is not yet available in your area, please write “no access” in the Email address field above. You will receive a paper copy of applicable manual updates, official notices, notices of rule making and provider memos in the mail.

ARKANSAS DEPARTMENT OF HUMAN SERVICES

DIVISION OF MEDICAL SERVICES

MEDICARE VERIFICATION FORM

Before we can enroll a provider as an Arkansas Medicaid provider, we must have verification of CURRENT Medicare enrollment. If you have documentation, i.e., EOMB, Medicare letter that is not over 6 months old and reflects the Medicare number and name of the enrolling provider, please attach a copy of the information to the application. If you do not have documentation, please submit this form to your Medicare intermediary and instruct them to complete the information requested below. After Medicare has completed the requested information and returned this form to you, you must then return this form with your completed Medicaid application. If your application is not returned with Medicare verification, enrollment in the Arkansas Medicaid Program will be denied.

Provider's Name _______________________________________________________________

(l) _____________________ ____________________ ___________________

Provider ID Number Effective Date End Date

(2) ______________________ ______________________

Social Security Number Tax I.D. Number

(3) ________________________________

Specialty of Practice or Taxonomy Code

This inquiry was completed by:


Name of Medicare Intermediary ____________________________________________

Address ____________________________________________


Telephone # _____________________________________________

Signature of Medicare Representative _______________________________________


_______________________________________

(Typed or Printed Name)


Date ________________________


(9) County: From the following list of codes, indicate the county that coincides with the place of service. If the services are provided in a bordering or out-of-state location, please use the county codes designated at the end of the code list.


County

County

Code

County

County

Code

County

County

Code

Arkansas

01

Garland

26

Newton

51

Ashley

02

Grant

27

Ouachita

52

Baxter

03

Greene

28

Perry

53

Benton

04

Hempstead

29

Phillips

54

Boone

05

Hot Spring

30

Pike

55

Bradley

06

Howard

31

Poinsett

56

Calhoun

07

Independence

32

Polk

57

Carroll

08

Izard

33

Pope

58

Chicot

09

Jackson

34

Prairie

59

Clark

10

Jefferson

35

Pulaski

60

Clay

11

Johnson

36

Randolph

61

Cleburne

12

Lafayette

37

Saline

62

Cleveland

13

Lawrence

38

Scott

63

Columbia

14

Lee

39

Searcy

64

Conway

15

Lincoln

40

Sebastian

65

Craighead

16

Little River

41

Sevier

66

Crawford

17

Logan

42

Sharp

67

Crittenden

18

Lonoke

43

St. Francis

68

Cross

19

Madison

44

Stone

69

Dallas

20

Marion

45

Union

70

Desha

21

Miller

46

Van Buren

71

Drew

22

Mississippi

47

Washington

72

Faulkner

23

Monroe

48

White

73

Franklin

24

Montgomery

49

Woodruff

74

Fulton

25

Nevada

50

Yell

75



















State

County

Code

State

County

Code

State

County

Code

Louisiana

91

Oklahoma

94

Texas

96

Missouri

92

Tennessee

95

All other states

97

Mississippi

93






























(10) Provider Category (A-C)

Enter the two-digit highlighted code, from the following list, which identifies the services the applicant will be providing.

A) __________________ B) ________________ C) ________________


Code Category Description

N3 Advanced Practice Nurse – Pediatrics

N4 Advanced Practice Nurse – Women’s Health

N6 Advanced Practice Nurse – Family

N7 Advanced Practice Nurse – Adult/Gerontological

N8 Advanced Practice Nurse – Psychiatric Mental Health

N9 Advanced Practice Nurse – Acute Care

N0 Advanced Practice Nurse– Nurse Practitioner - Other

03 Allergy/Immunology

A8 Alternatives for Adults with Physical Disabilities (Alternative) - Environmental Adaptations

A9 Alternatives for Adults with Physical Disabilities (Alternative) - Attendant Care Services

A4 Ambulatory Surgical Center

AA Adolescent Medicine

  1. Anesthesiology

AV Autism Intensive Intervention Provider

AW Autism Consultant

AX Autism Lead/Line Therapist

AZ Autism Clinical Service Specialist

AH Living Choices Assisted Living Agency

AL Living Choices Assisted Living Facility—Direct Services Provider

AP Living Choices Assisted Living Pharmacist Consultant

64 Audiologist

C1 Cancer Screen (Health Dept. Only)

C2 Cancer Treatment (Health Dept. Only)

06 Cardiovascular Disease

C4 Child Health Management Services

CF Child Health Management Services – Foster Care

  1. Chiropractor

C8 Communicable Diseases (Health Dept. Only)

C3 CRNA

HA ACS Waiver Environmental Modifications/Adaptive Equipment

HB ACS Waiver Specialized Medical Supplies

HC ACS Waiver Case Management/Transitional Case Management/Community Transition Services

HE ACS Waiver Supported Employment

H7 ACS Waiver Supportive Living/Respite/Supplemental Support

HG ACS Waiver Crisis Intervention

H9 ACS Waiver Consultation Services

IC IndependentChoices

HF ACS Waiver Organized HealthCare Delivery System

N5 DDS Non-Medicaid

V2 Dental

V1 Dental Clinic (Health Dept. Only)

V0 Dental - Mobile Dental Facility

X5 Dental - Oral Surgeon

V6 Dental - Orthodontia

07 Dermatology

V3 Developmental Day Treatment Center

DR Developmental Rehabilitation Services

V5 Domiciliary Care

CN DYS/TCM Group

CO DYS/TCM Performing

E4 ElderChoices H&CB 2176 Waiver - Chore services

E5 ElderChoices H&CB 2176 Waiver - Adult Family Homes

E6 ElderChoices H&CB 2176 Waiver - Home maker

E7 ElderChoices H&CB 2176 Waiver - Home delivered hot meals

EC ElderChoices H&CB 2176 Waiver - Home delivered frozen meals

E8 ElderChoices H&CB 2176 Waiver - Personal emergency response systems

E9 ElderChoices H&CB 2176 Waiver - Adult day care

EA ElderChoices H&CB 2176 Waiver - Adult day health care

EB ElderChoices H&CB 2176 Waiver - Respite care

E1 Emergency Medicine

(10) Provider Category (Continued)


Code Category Description

E2 Endocrinology

E3 Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

F1 Family Planning

08 Family Practice

F2 Federally Qualified Health Center

10 Gastroenterology

01 General Practice

38 Geriatrics

16 Gynecology - Obstetrics

H1 Hearing Aid Dealer

H2 Hematology

H5 Hemodialysis

H3 Home Health

H6 Hospice

A5 Hospital - AR State Operating Teaching Hospital

W6 Hospital – Inpatient

W7 Hospital - Outpatient

CH Hospital – Critical Access

IH Hospital – Indian Health Services

IS Hospital – Indian Health Services Freestanding

P7 Hospital - Pediatric Inpatient

P8 Hospital - Pediatric Outpatient

R7 Hospital - Rural Inpatient

HN Hyperalimentation Enteral Nutrition – Sole Source

H4 Hyperalimentation Parenteral Nutrition – Sole Source

V8 Immunization (Health Dept. Only)



69 Independent Lab

55 Infectious Diseases

W3 Inpatient Psychiatric - under 21

WA Inpatient Psychiatric - Residential Treatment Unit within Inpatient Psychiatric Hospital

WB Inpatient Psychiatric - Residential Treatment Center

WC Inpatient Psychiatric - Sexual Offenders Program

W4 Intermediate Care Facility

W9 Intermediate Care Facility – Infant Infirmaries

W5 Intermediate Care Facility - Mentally Retarded

11 Internal Medicine

L1 Laryngology

M1 Maternity Clinic (Health Dept. Only)

M4 Medicare/Medicaid Crossover Only

WI Mental Health Practitioner – Licensed Certified Social Worker

W2 Mental Health Practitioner – Licensed Professional Counselor

R5 Mental Health Practitioner – Licensed Marriage and Family Therapist

62 Mental Health Practitioner - Psychologist

N1 Neonatology

39 Nephrology

13 Neurology

NI Nuclear Medicine

N2 Nurse Midwife

N3 Nurse Practitioner – Pediatric

N4 Nurse Practitioner - OB/GYN

N6 Nurse Practitioner – Family Practice

N7 Nurse Practitioner - Gerontological

RK Offsite Intervention Service - Outpatient Mental and Behavioral Health (ARKids ONLY)

X1 Oncology

  1. Ophthalmology

X2 Optical Dispensing Contractor

X4 Optometrist

X6 Orthopedic

12 Osteopathy - Manipulative Therapy

X7 Osteopathy - Radiation Therapy

X8 Otology

X9 Otorhinolaryngology

22 Pathology

37 Pediatrics

(10) Provider Category (Continued)


Code Category Description

P1 Personal Care Services
PA Personal Care Services / Area Agency on Aging

PD Personal Care Services / Developmental Disability Services

PE Personal Care Services / Week-end

PG Personal Care Services / Level I Assisted Living Facility

PH Personal Care Services / Level II Assisted Living Facility

R3 Personal Care Services / Residential Care Facility

PS Personal Care Services: Public School or Education Service Cooperative

P2 Pharmacy Independent

PC Pharmacy – Chain

PM Pharmacy – Compounding

PN Pharmacy – Home Infusion

PR Pharmacy – Long Term Care / Closed Door

PV Pharmacy – Administrated Vaccines

P3 Physical Medicine

48 Podiatrist

63 Portable X-ray Equipment

P6 Private Duty Nursing

PF Private Duty Nursing: Public School or Education Service Cooperative

28 Proctology

P4 Prosthetic Devices

V4 Prosthetic - Durable Medical Equipment/Oxygen

Z1 Prosthetic - Orthotic Appliances

26 Psychiatry

P5 Psychiatry - Child

29 Pulmonary Diseases

R9 Radiation Therapy - Complete

RA Radiation Therapy - Technical

30 Radiology - Diagnostic

31 Radiology - Therapeutic

R6 Rehabilitative Services for Persons with Mental Illness

RC Rehabilitative Services for Persons with Physical Disabilities

R1 Rehabilitative Hospital

RJ Rehabilitative Services for Youth and Children DCFS

RL Rehabilitative Services for Youth and Children DYS

CR Respite Care – Children’s Medical Services

R4 Rheumatology

R2 Rural Health Clinic - Provider Based

R8 Rural Health Clinic - Independent Freestanding

S7 School Based Health Clinic - Child Health Services

S8 School Based Health Clinic - Hearing Screener

S9 School Based Health Clinic - Vision Screener

SA School Based Health Clinic - Vision & Hearing Screener

SB School Based Audiology

VV School Based Mental Health Clinic

SO School District Outreach for ARKids

S5 Skilled Nursing Facility

W8 Skilled Nursing Facility – Special Services

S6 SNF Hospital Distinct Part Bed

S1 Surgery - Cardio

S2 Surgery - Colon & Rectal

O2 Surgery - General

14 Surgery - Neurological

20 Surgery - Orthopedic

53 Surgery - Pediatric

54 Surgery - Oncology

24 Surgery - Plastic & Reconstructive

33 Surgery - Thoracic

S4 Surgery - Vascular

C5 Targeted Case Management - Ages 60 and Older

C6 Targeted Case Management - Ages 00 - 20

C7 Targeted Case Management - Ages 21 – 59

CM Targeted Case Management – Developmental Disabilities Certification – Ages 00 - 20

T6 Therapy - Occupational

(10) Provider Category (Continued)


Code Category Description

T1 Therapy - Physical

T2 Therapy - Speech Pathologist

TO Therapy - Occupational Assistant

TP Therapy - Physical Assistant

TS Therapy - Speech Pathologist Assistant

A1 Transportation - Ambulance, Emergency

A2 Transportation - Ambulance, Non-emergency

A6 Transportation - Advanced Life Support with EKG

A7 Transportation - Advanced Life Support without EKG

TA Transportation - Air Ambulance/Helicopter

TB Transportation - Air Ambulance/Fixed Wing

TD Transportation - Broker

TC Transportation - Non-Emergency

TH Tuberculosis (Health Dept. Only)

34 Urology

V7 Ventilator Equipment
(11) Certification Code: This code identifies the type of provider the certification number in field 12 defines. If an entry is made in this field (11), an entry MUST be made in field 12 and 13 unless the entry is a 5. Please check the appropriate code.
0 = Mental Health [ ]

1 = Home Health [ ]

2 = CRNA [ ]

3 = Nursing Home [ ]

4 = Other [ ]

5 = Non-applicable [ ]


(12) Certification Number: If applicable, enter the certification number assigned to the applicant by the appropriate certification board/agency.


A CURRENT COPY OF THIS CERTIFICATION MUST ACCOMPANY THIS APPLICATION.
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____

(13) End Date: Enter the expiration date of the applicant's current certification number in month/day/year format.


____ ____/____ ____/ ____ ____

MM DD Year


(14) Fiscal Year: Enter the date of the applicant's fiscal year end. This date is in month/day format.
____ ____/____ ____

MM DD


(15) DEA Number: If applicable, enter the number assigned to the applicant by the Federal Drug Enforcement Agency. Pharmacies must submit this information to be enrolled.
Required for Pharmacies and Dental Surgeons

A CURRENT COPY OF THIS CERTIFICATE MUST ACCOMPANY THIS APPLICATION.
_____ _____ _____ _____ _____ _____ _____ _____ _____

(16) End Date: Enter the expiration date of the current DEA Number in month/day/year format.


____ ____/____ ____/ ____ ____

MM DD Year

(17) License Number: If applicable, enter the license number assigned to the applicant by the appropriate state licensure board. If the license issued is a temporary license enter TEMP. If the license number is smaller than the fields allowed, leave the last spaces blank.
A CURRENT COPY OF THIS LICENSE MUST ACCOMPANY THIS APPLICATION.
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____

(18) End Date: Enter the expiration date of the applicant's current license in month/day/year format.

____ ____/____ ____/ ____ ____

MM DD Year


(19) CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA): If applicable, enter the CLIA number assigned to the applicant. A copy of the CLIA certificate is required in order to have your laboratory test paid.


_____ _____ _____ _____ _____ _____ _____ _____ _____ _____

FOR OFFICE USE ONLY
Provider ID Number Pending

Taxonomy Code____________________________________ Computer

Provider Name OK to Key

Keyed

Maintenance Checked

SECTION II: FACILITIES ONLY
(20) Special Facility Program: Check the appropriate value to depict if the applicant's facility is indigent care, teaching facility/university or UR plan. Special facility program values include:
*A = indigent care only [ ]

**B = teaching facility/university only [ ]

***C = UR plan only [ ]

D = A/B [ ]

E = A/C [ ]

F = B/C [ ]

G = A/B/C [ ]

N = No special program [ ]


* Indigent Care - Indicate whether the facility is qualified for the indigent care allowance.
NOTE: Facilities which serve a disproportionate number of indigent patients (defined as exceeding 20% Medicaid days as compared to a total patient day) may qualify for an indigent care allowance. If the facility meets the above criteria, please send the appropriate excerpt from the most current cost report that reflects total Medicaid days and total patient days.
** Teaching/University Facility - Indicate whether the facility is designated as a teaching/university affiliated institution and participates in three or more residency training programs.
*** Utilization Review Plan - Does the facility have a Utilization Review Plan applicable to all Medicaid patients?

(21) Total Beds: Enter the total number of beds in the facility.


___________________________________

# of Beds


FOR OFFICE USE ONLY
Provider ID Number Pending

Taxonomy Code ____________________________________ Computer

Provider Name OK to Key

Keyed

Maintenance Checked


SECTION III: PHARMACIST/REGISTERED RESPIRATORY THERAPIST ONLY
PHARMACIES - PLEASE INDICATE IF THIS APPLICANT IS A CHAIN-OWNED PHARMACY WITH 11 OR MORE RETAIL PHARMACIES NATIONALLY. (FRANCHISES WHICH ARE INDIVIDUALLY OWNED ARE NOT CHAIN-OWNED UNLESS ONE INDIVIDUAL OR CORPORATION OWNS 11 OR MORE RETAIL STORES.)

YES NO
(22) Please list each pharmacist/registered respiratory therapist name, Social Security Number, license number and effective date of employment.
Please indicate by the pharmacist name whether that pharmacist is certified to administer Vaccines. If you are providing Vaccines, the pharmacy will need to be enrolled in the Medicare program. Please include the pharmacy Medicare Billing Provider ID Number on the Medicare Verification Form and attach proof of Medicare enrollment to the application. Please refer to the Medicare Verification Form for proof of Medicare requirements.
A copy of current registered respiratory therapist is required. Subsequent renewal must be provided when issued.
NOTE: Registered Respiratory Therapists must enter registration number in license number field.
___________________________ _____________________ Administering Vaccines (see above)

Name of Pharmacist/ Social Security Number ______ _______

Registered Respiratory Therapist yes no
___________________________________________ ______________________

License/Registration Number Effective Date of employment


___________________________ _____________________ Administering Vaccines (see above)

Name of Pharmacist/ Social Security Number ______ _______

Registered Respiratory Therapist yes no
___________________________________________ ______________________

License/Registration Number Effective Date of employment


___________________________ _____________________ Administering Vaccines (see above)

Name of Pharmacist/ Social Security Number ______ _______

Registered Respiratory Therapist yes no
___________________________________________ ______________________

License/Registration Number Effective Date of employment


___________________________ _____________________ Administering Vaccines (see above)

Name of Pharmacist/ Social Security Number ______ _______

Registered Respiratory Therapist yes no
___________________________________________ ______________________

License/Registration Number Effective Date of employment



FOR OFFICE USE ONLY

Provider ID Number Pending

Taxonomy Code ____________________________________ Computer

OK to Key

Provider Name______________________________________ Keyed

Maintenance Checked

SECTION IV: PROVIDER GROUP AFFILIATIONS
(23) If the applicant is affiliated with a group practice or an organization that is authorized to submit Medicaid claims on their behalf, the applicant must complete this section and sign the Appointment of Billing Intermediary Statement. Add extra sheets if necessary.

_______________________________ _______________________ _____ ________________

Last Name First Name M. I. Title
________________________________________________________________________________________

Group Organization Name


__________________________________ _______________________________________

Group Provider ID Number Effective Date (Applicant Joined Group)


__________________________________ _______________________________________

Group Taxonomy Code Expiration Date (Applicant Left Group)
_________________________________________ _________ __________________

City State Zip Code


The undersigned Provider authorizes the above-listed Group Practice Organization to submit claims to the Arkansas Division of Medical Services (hereinafter the Division) on his/her/its behalf, in accordance with the applicable Division regulations. The Provider also authorizes the Division to issue payment checks on his/her/its behalf to the above listed Group Practice Organization, in accordance with applicable Division requirements.
The Provider accepts full liability to the Division for all acts committed by each Group Practice Organization listed above which relate in any manner to said Group Practice Organization's performance of duties in preparing and submitting claims on the Provider's behalf within the scope of its actual or apparent authority. Should any such acts result in the violation of any of the laws, rules or regulations governing the Medical Assistance Program or the Provider's agreement with the Division, the Provider shall be fully liable to the Division as if such acts were the Provider's own acts.
The Provider agrees to notify the Division at least ten days prior to the effective date of the revocation of this Appointment of Billing Intermediary. In such event, the Provider's liability for the acts of the Group Practice Organization shall continue until the tenth day after the Department's receipt of such notification or the effective date of the revocation, whichever date is later.
An original or approved electronic signature of the individual provider is mandatory. (No stamped or copied signature is allowed; “approved electronic signature” is described at the Arkansas Medicaid website, https://www.medicaid.state.ar.us/.)
__________________________________________ ____________________ ______________________

Signature Title Date


___________________________________

______________________ ____________________ Provider ID Number

Typed or Printed Name

____________________________________

Provider Taxonomy Code

Primary Care Physicians must complete the Primary Care Physician Agreement in order to have their managed care fees paid to a new group Provider ID Number. (See item 25)

FOR OFFICE USE ONLY

Provider ID Number Pending

Taxonomy Code ____________________________________ Computer

OK to Key

Provider Name______________________________________ Keyed

Maintenance Checked

SECTION IV: PROVIDER GROUP AFFILIATIONS
(23) If the applicant is affiliated with a group practice or an organization that is authorized to submit Medicaid claims on their behalf, the applicant must complete this section and sign the Appointment of Billing Intermediary Statement. Add extra sheets if necessary.

_______________________________ _______________________ _____ ________________

Last Name First Name M. I. Title
________________________________________________________________________________________

Group Organization Name


__________________________________ _______________________________________

Group Provider ID Number Effective Date (Applicant Joined Group)


__________________________________ _______________________________________

Group Taxonomy Code Expiration Date (Applicant Left Group)
_________________________________________ _________ __________________

City State Zip Code


The undersigned Provider authorizes the above-listed Group Practice Organization to submit claims to the Arkansas Division of Medical Services (hereinafter the Division) on his/her/its behalf, in accordance with the applicable Division regulations. The Provider also authorizes the Division to issue payment checks on his/her/its behalf to the above listed Group Practice Organization, in accordance with applicable Division requirements.
The Provider accepts full liability to the Division for all acts committed by each Group Practice Organization listed above which relate in any manner to said Group Practice Organization's performance of duties in preparing and submitting claims on the Provider's behalf within the scope of its actual or apparent authority. Should any such acts result in the violation of any of the laws, rules or regulations governing the Medical Assistance Program or the Provider's agreement with the Division, the Provider shall be fully liable to the Division as if such acts were the Provider's own acts.
The Provider agrees to notify the Division at least ten days prior to the effective date of the revocation of this Appointment of Billing Intermediary. In such event, the Provider's liability for the acts of the Group Practice Organization shall continue until the tenth day after the Department's receipt of such notification or the effective date of the revocation, whichever date is later.
An original or approved electronic signature of the individual provider is mandatory. (No stamped or copied signature is allowed; “approved electronic signature” is described at the Arkansas Medicaid website, https://www.medicaid.state.ar.us/.)
__________________________________________ ____________________ ______________________

Signature Title Date


___________________________________

______________________ ____________________ Provider ID Number

Typed or Printed Name

____________________________________



Provider Taxonomy Code

Primary Care Physicians must complete the Primary Care Physician Agreement in order to have their managed care fees paid to a new group Provider ID Number. (See item 25)


DMS-652 (R. 1/16)


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