016.06.10 Ark. Code R. 021
Dental Services Provided by a Mobile Dental Facility
A mobile dental facility is any self-contained, intact facility in which dentistry and dental hygiene are practiced and that may be towed, moved or transported from one location to another.
A mobile dental facility must enroll by completing the Arkansas Medicaid provider application and contract. Mobile dental facilities must meet all criteria of a dental group and submit the same enrollment documentation stated in Section 141.000 and Section 201.000. Additionally, mobile dental facilities must maintain and submit with their Arkansas Medicaid provider application and contract a copy of their mobile facility permit issued by the Arkansas State Board of Dental Examiners. Each individual dentist practicing within the mobile dental facility must also be an Arkansas Medicaid provider and will need to complete Section IV "Group Affiliation" of the Arkansas Medicaid provider application.
NOTE: Mobile providers of Dental or Oral and Maxillofacial Surgeon Services in bordering and non-bordering states cannot enroll.
Billing Procedures
All mobile dental facilities are "pay to" providers only. This service must be performed and billed by a licensed/enrolled dentist with the mobile facility.
NOTE: For providers filing on the paper ADA claim form, mark section 38, select the appropriate POS and complete section 56 (service address).
DIVISION OF MEDICAL SERVICES
MEDICAL ASSISTANCE PROGRAM
PROVIDER APPLICATION
As a condition for entering into or renewing a provider agreement, all applicants must complete this provider application. A true, accurate and complete disclosure of all requested information is required by the Federal and State Regulations that govern the Medical Assistance Program. Failure of an applicant to submit the requested information or the submission of inaccurate or incomplete information may result in refusal by the Medical Assistance program to enter into, renew or continue a provider agreement with the applicant. Furthermore, the applicant is required by Federal and State Regulations to update the information submitted on the Provider Application.
Whenever changes in this information occur, please submit the change in writing to:
Medicaid Provider Enrollment Unit
HP Enterprise Services
P.O. Box 8105
Little Rock, AR 72203-8105
All dates, except where otherwise specified, should be written in the month/day/year (MMDDYY) format. Please print all information.
This information is divided into sections. The following describes which sections are to be completed by the 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 |
ARKANSAS DEPARTMENT OF HUMAN SERVICES DIVISION OF MEDICAL SERVICES
MEDICARE VERIFICATION FORM
County | County Code |
Arkansas | 01 |
Ashley | 02 |
Baxter | 03 |
Benton | 04 |
Boone | 05 |
Bradley | 06 |
Calhoun | 07 |
Carroll | 08 |
Chicot | 09 |
Clark | 10 |
Clay | 11 |
Cleburne | 12 |
Cleveland | 13 |
Columbia | 14 |
Conway | 15 |
Craighead | 16 |
Crawford | 17 |
Crittenden | 18 |
Cross | 19 |
Dallas | 20 |
Desha | 21 |
Drew | 22 |
Faulkner | 23 |
Franklin | 24 |
Fulton | 25 |
Garland | 26 |
Grant | 27 |
Greene | 28 |
Hempstead | 29 |
Hot Spring | 30 |
Howard | 31 |
Independence | 32 |
Izard | 33 |
Jackson | 34 |
Jefferson | 35 |
Johnson | 36 |
Lafayette | 37 |
Lawrence | 38 |
Lee | 39 |
Lincoln | 40 |
Little River | 41 |
Logan | 42 |
Lonoke | 43 |
Madison | 44 |
Marion | 45 |
Miller | 46 |
Mississippi | 47 |
Monroe | 48 |
Montgomery | 49 |
Nevada | 50 |
Newton | 51 |
Ouachita | 52 |
Perry | 53 |
Phillips | 54 |
Pike | 55 |
Poinsett | 56 |
Polk | 57 |
Pope | 58 |
Prairie | 59 |
Pulaski | 60 |
Randolph | 61 |
Saline | 62 |
Scott | 63 |
Searcy | 64 |
Sebastian | 65 |
Sevier | 66 |
Sharp | 67 |
St. Francis | 68 |
Stone | 69 |
Union | 70 |
Van Buren | 71 |
Washington | 72 |
White | 73 |
Woodruff | 74 |
Yell | 75 |
Louisiana | 91 |
Missouri | 92 |
Mississippi | 93 |
Oklahoma | 94 |
Tennessee | 95 |
Texas | 96 |
All other states | 97 |
Code | Category Description |
N3 | Advanced Practice Nurse - Pediatrics |
N4 | Advanced Practice Nurse-Women's Health |
N6 | Advanced Practice Nurse - Family |
N7 | Advanced Practice Nurse-Adult/Gerontological |
N8 | Advanced Practice Nurse - Psychiatric Mental Health |
N9 | Advanced Practice Nurse -Acute Care |
NO | Advanced Practice Nurse- Nurse Practitioner- Other |
03 | Allergy/Immunology |
A8 | Alternatives for Adults with Physical Disabilities (Alternative) - Environmental Adaptations |
A9 | Alternatives for Adults with Physical Disabilities (Alternative) -Attendant Care Services |
A4 | Ambulatory Surgical Center |
AA | Adolescent Medicine |
05 | Anesthesiology |
AH | Living Choices Assisted Living Agency |
AL | Living Choices Assisted Living Facility-Direct Services Provider |
AP | Living Choices Assisted Living Pharmacist Consultant |
64 | Audiologist |
C1 | Cancer Screen (Health Dept. Only) |
C2 | Cancer Treatment (Health Dept. Only) |
06 | Cardiovascular Disease |
C4 | Child Health Management Services |
CF | Child Health Management Services - Foster Care |
35 | Chiropractor |
C8 | Communicable Diseases (Health Dept. Only) |
C3 | CRNA |
HA | DDS ACS Waiver Physical Adaptations |
HB | DDS ACS Waiver Specialized Medical Supplies |
HC | DDS ACS Waiver Case Management Services |
HE | DDS ACS Waiver Supported Employment |
H7 | DDS ACS Waiver Supportive Living |
H8 | DDS ACS Waiver Crisis Abatement Services |
HG | DDS ACS Waiver Crisis Center- Intervention Services |
H9 | DDS ACS Waiver Consultation Services |
IC | DDS ACS Waiver IndependentChoices |
HF | DDS ACS Waiver Organized Healthcare |
N5 | DDS Non-Medicaid |
V2 | Dental |
V1 | Dental Clinic (Health Dept. Only) |
VO | 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 |
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 | Larynology |
M1 | Maternity Clinic (Health Dept. Only) |
M4 | Medicare/Medicaid Crossover Only |
Wl | Mental Health Practitioner- Licensed Certified Social Worker |
W2 | Mental Health Practitioner- Licensed Professional Counselor |
R5 | Mental Health Practitioner- Licensed Marriage and Family Therapist |
62 | Mental Health Practitioner- Psychologist |
N1 | Neonatology |
39 | Nephrology |
13 | Neurology |
Nl | Nuclear Medicine |
N2 | Nurse Midwife |
N3 | Nurse Practitioner- Pediatric |
N4 | Nurse Practitioner - OB/GYN |
N6 | Nurse Practitioner- Family Practice |
N7 | Nurse Practitioner- Gerontological |
RK | Offsite Intervention Service - Outpatient Mental and Behavioral Health (ARKids ONLY) |
X1 | Oncology |
18 | Ophthalmology |
X2 | Optical Dispensing Contractor |
X4 | Optometrist |
X6 | Orthopedic |
12 | Osteopathy - Manipulative Therapy |
X7 | Osteopathy - Radiation Therapy |
X8 | Otology |
X9 | Otorhinolaryngology |
22 | Pathology |
37 | Pediatrics |
P1 | Personal Care Services |
PA | Personal Care Services / Area Agency on Aging |
PD | Personal Care Services / Developmental Disability Services |
PE | Personal Care Services / Week-end |
PG | Personal Care Services / Level I Assisted Living Facility |
PH | Personal Care Services / Level II Assisted Living Facility |
R3 | Personal Care Services / Residential Care Facility |
PS | Personal Care Services: Public School or Education Service Cooperative |
P2 | Pharmacy Independent |
PC | Pharmacy-Chain |
PM | Pharmacy - Compounding |
PN | Pharmacy - Home Infusion |
PR | Pharmacy - Long Term Care / Closed Door |
PV | Pharmacy - Administrated Vaccines |
P3 | Physical Medicine |
48 | Podiatrist |
63 | Portable X-ray Equipment |
P6 | Private Duty Nursing |
PF | Private Duty Nursing: Public School or Education Service Cooperative |
28 | Proctology |
P4 | Prosthetic Devices |
V4 | Prosthetic - Durable Medical Equipment/Oxygen |
Z1 | Prosthetic - Orthotic Appliances |
26 | Psychiatry |
P5 | Psychiatry- Child |
29 | Pulmonary Diseases |
R9 | Radiation Therapy - Complete |
RA | Radiation Therapy - Technical |
30 | Radiology - Diagnostic |
31 | Radiology - Therapeutic |
R6 | Rehabilitative Services for Persons with Mental Illness |
RC | Rehabilitative Services for Persons with Physical Disabilities |
R1 | Rehabilitative Hospital |
RJ | Rehabilitative Services for Youth and Children DCFS |
RL | Rehabilitative Services for Youth and Children DYS |
CR | Respite Care - Children's Medical Services |
R4 | Rheumatology |
R2 | Rural Health Clinic - Provider Based |
R8 | Rural Health Clinic - Independent Freestanding |
S7 | School Based Health Clinic - Child Health Services |
S8 | School Based Health Clinic - Hearing Screener |
S9 | School Based Health Clinic - Vision Screener |
SA | School Based Health clinic - Vision & Hearing Screener |
W | School Based Mental Health Clinic |
SO | School District Outreach for ARKids |
S5 | Skilled Nursing Facility |
W8 | Skilled Nursing Facility- Special Services |
S6 | SNF Hospital Distinct Part Bed |
S1 | Surgery- Cardio |
S2 | Surgery - Colon & Rectal |
02 | Surgery- General |
14 | Surgery - Neurological |
20 | Surgery - Orthopedic |
53 | Surgery - Pediatric |
54 | Surgery- Oncology |
24 | Surgery - Plastic & Reconstructive |
33 | Surgery - Thoracic |
S4 | Surgery - Vascular |
C5 | Targeted Case Management - Ages 60 and Older |
C6 | Targeted Case Management - Ages 00 - 20 |
C7 | Targeted Case Management - Ages 21 - 59 |
CM | Targeted Case Management - Developmental Disabilities Certification - Ages 00 - 20 |
T6 | Therapy - Occupational |
T1 | Therapy - Physical |
T2 | Therapy - Speech Pathologist |
TO | Therapy - Occupational Assistant |
TP | Therapy - Physical Assistant |
TS | Therapy - Speech Pathologist Assistant |
A1 | Transportation -Ambulance, Emergency |
A2 | Transportation -Ambulance, Non-emergency |
A6 | Transportation - Advanced Life Support with EKG |
A7 | Transportation - Advanced Life Support without EKG |
TA | Transportation - Air Ambulance/Helicopter |
TB | Transportation - Air Ambulance/Fixed Wing |
TD | Transportation - Broker |
TC | Transportation - Non-Emergency |
TH | Tuberculosis (Health Dept. Only) |
34 | Urology |
V7 | Ventilator Equipment |
016.06.10 Ark. Code R. 021