016-06-10 Ark. Code R. § 21

Current through Register Vol. 49, No. 6, June, 2024

Rule 016.06.10-021 - Dental-3-10 and Section V-8-10

Section II Dental

212.300Dental Services Provided by a Mobile Dental Facility 1-1-11

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

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ARKANSAS DEPARTMENT OF HUMAN SERVICES DIVISION OF MEDICAL SERVICES

MEDICARE VERIFICATION FORM

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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

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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

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016.06.10 Ark. Code R. § 021

12/14/2010