016-06-15 Ark. Code R. § 17
Attributed beneficiaries | The Medicaid beneficiaries for whom primary care physicians and participating practices have accountability under the PCMH program. A primary care physician's attributed beneficiaries are determined by the ConnectCare Primary Care Case Management (PCCM) program. Attributed beneficiaries do not include dual eligible beneficiaries. |
Attribution | The methodology by which Medicaid determines beneficiaries for whom a participating practice may receive practice support and shared savings incentive payments. |
Benchmark cost | The projected cost of care for a specific shared savings entity against which savings are measured. Benchmark costs are expressed as an average amount per beneficiary. |
Benchmark trend | The fixed percentage growth applied to PCMH practices' historical baseline fixed costs of care to project benchmark cost. |
Care coordination | The ongoing work of engaging beneficiaries and organizing their care needs across providers and care settings. |
Care coordination payment | Quarterly payments made to participating practices to support care coordination services. Payment amount is calculated per attributed beneficiary, per month. |
Cost thresholds | Cost thresholds are the per beneficiary cost of care values (high and medium) against which a shared savings entity's per beneficiary cost is measured. |
Default pool | A pool of beneficiaries who are attributed to participating practices that do not meet the requirements in Section 233.000, part A or part B. |
Historical baseline cost of care | A multi-year weighted average of a shared savings entity's per beneficiary cost of care. |
Medical neighborhood barriers | Obstacles to the delivery of coordinated care that exist in areas of the health system external to PCMH. |
Minimum savings rate | A fixed percentage set by DMS. In order to receive shared savings incentive payments for performance improvement described in Section 237.000, part A, a shared savings entity must achieve a per beneficiary cost of care that is below its benchmark cost by at least the minimum savings rate. |
Participating practice | A physician practice that is enrolled in the PCMH program, which must be one of the following: A. An individual primary care physician (Provider Type 01 or 03); B. A physician group of primary care providers who |
are affiliated, with a common group identification number (Provider Type 02, 04 or 81); C. A Rural Health Clinic (Provider Type 29) as defined in the Rural Health Clinic Provider Manual Section 201.000; or D. An Area Health Education Center (Provider type 69). | |
Patient-Centered Medical Home (PCMH) | A team-based care delivery model led by Primary Care Physicians (PCPs) who comprehensively manage beneficiaries' health needs with an emphasis on health care value. |
Per beneficiary cost of care | The risk- and time-adjusted average of attributed beneficiaries' total Medicaid fee-for-service claims (based on the published reimbursement methodology) during the performance period, net of exclusions. |
Per beneficiary cost of care floor | The lowest per beneficiary cost of care for which practices within a shared savings entity can receive shared savings incentive payments. |
Per beneficiary savings | The difference between a shared savings entity's benchmark cost and its per beneficiary cost of care in a given performance period. |
Performance period | The period of time over which performance is aggregated and assessed. |
Pool | A. The beneficiaries who are attributed to one or more participating practice(s) for the purpose of forming a shared savings entity; or B. The action of aggregating beneficiaries for the purposes of shared savings incentive payment calculations (i.e., the action of forming a shared savings entity). |
Practice support | Support provided by Medicaid in the form of care coordination payments to a participating practice and practice transformation support provided by a DMS contracted vendor. |
Practice transformation | The adoption, implementation and maintenance of approaches, activities, capabilities and tools that enable a participating practice to serve as a PCMH. |
Primary Care Physician (PCP) | See Section 171.000 of the Arkansas Medicaid provider manual. |
Provider portal | The website that participating practices use for purposes of enrollment, reporting to the Division of Medical Services (DMS) and receiving information from DMS. |
Recover | To deduct an amount from a participating practice's future Medicaid receivables, including without limitation, PCMH payments, or fee-for-service reimbursements, to recoup such amount through legal process, or both. |
Remediation time | The period during which participating practices that fail to meet deadlines, targets or both on relevant activities and |
metrics tracked for practice support may continue to receive care coordination payments while improving performance. | |
Risk adjustment | An adjustment to the cost of beneficiary care to account for patient risk. |
Same-day appointment request | A beneficiary request to be seen by a clinician within 24 hours. |
Shared savings entity | A PCMH or pooled PCMHs that, contingent on performance, may receive shared savings incentive payments. |
Shared savings incentive payment cap | The maximum shared savings incentive payment that DMS will pay to a shared savings entity, expressed as a percentage of that entity's benchmark cost for the performance period. |
Shared savings incentive payments | Annual payments made to reward cost-efficient and quality care. |
Shared savings percentage | The percentage of a shared savings entity's total savings that is paid to the PCMH in a shared savings entity. |
State Health Alliance for Records Exchange (SHARE) | The Arkansas Health Information Exchange. For more information, qo to http://ohit.arkansas.aov. |
To be eligible to enroll in the PCMH program:
DMS may modify the number of attributed beneficiaries required for enrollment based on provider experience and will publish at www.pavmentinitiative.organy such modification.
Enrollment in the PCMH program is voluntary and practices must re-enroll annually. To enroll, practices must access the Advanced Health Information Network (AHIN) provider portal and submit a complete and accurate Arkansas Medicaid Patient-Centered Medical Home Practice Participation Agreement (DMS-844). The AHIN portal can be accessed at www.pavmentinitiative.org/medicalHomes/Pages/Enrollment-Process.aspx. Once enrolled, a participating PCMH remains in the PCMH program until:
A physician may be affiliated with only one participating practice. A participating practice must update the Department of Human Services (DHS) on changes to the list of physicians who are part of the practice. Physicians who are no longer participating within a practice are required to update in writing via email at ARKPCMH(S)hp.comwithin 30 days of the change.
To withdraw from the PCMH program, the participating practice must email a complete and accurate Arkansas Patient-Centered Medical Home Withdrawal Form (DMS-846) to ARKPCMH(S)hp.com. View or print the Arkansas Patient-Centered Medical Home Withdrawal Form (DMS-846)or download the form from the AHIN provider portal.
Enrollment is open for approximately 3 months in Quarter 3 and Quarter 4 of the preceding calendar year.
DMS will not accept any enrollment documents received other than during an enrollment period.
A participating practice must manage its caseload of attributed beneficiaries, including removal of a beneficiary from its panel. DMS retains the right to disallow beneficiary removals if it was determined it was done so to dismiss high costs and/or high-risk patients from the panel.
Practice support includes both care coordination payments made to a PCMH and practice transformation support provided by a Division of Medical Services (DMS) contracted vendor and is subject to funding limitations on the part of DMS.
Receipt and use of the care coordination payments is not conditioned on the PCMH engaging a care coordination vendor, as payment can be used to support participating practices' investments (e.g., time and energy) in enacting changes to achieve PCMH goals. Care coordination payments are risk-adjusted to account for the varying levels of care coordination services needed for beneficiaries with different risk profiles.
DMS will contract with a practice transformation vendor on behalf of PCMHs that require additional support to catalyze practice transformation and retain and use such vendor. PCMHs must maintain documentation of the months they have contracted with a practice transformation vendor. Practice transformation vendors must report to DMS the level and type of service delivered to each PCMH. Payments to a practice transformation vendor on behalf of a participating practice may continue for up to 24 months.
However, no practice support may extend beyond June 30, 2017, regardless of the number of months practice support was received by a practice. PCMHs may contract with only one vendor at a given time. PCMHs are able to change vendors at any time with notification in writing to the outgoing vendor and DMS. Failure to provide written notification will result in the PCMH being liable for any duplicate payments.
DMS may pay, recover or offset overpayment or underpayment of care coordination payments.
DMS will also support PCMHs through improved access to information through the reports described in Section 244.000.
In addition to the enrollment eligibility requirements listed in Section 211.000, in order for PCMHs to receive practice support, DMS measures PCMH performance against activities tracked for practice support identified in Section 241.000. PCMHs must meet the requirements of this section to receive practice support.
Each PCMH in a shared entity will, if individually qualified, receive practice support even if another PCMH in a shared savings entity does not qualify for practice support.
The care coordination payment is risk adjusted based on factors including demographics (age, sex), diagnoses and utilization. DMS will publish the current payment scale at www.pavmentinitiative.org/referenceMaterials/Documents/2016PCMHProgramPolicvAdde ndum.pdf.
After each quarter, DMS may pay, recover or offset the care coordination payments to ensure that a PCMH did not receive a care coordination payment for any beneficiary who died, lost eligibility or if the practice lost eligibility during the quarter.
If a PCMH withdraws from the PCMH program, then the PCMH is only eligible for care coordination payments based on a complete quarter's participation in the PCMH program.
To receive shared savings incentive payments, a shared savings entity must have a minimum of 5,000 attributed beneficiaries once the exclusions listed below have been applied. A shared savings entity may meet this requirement as a single PCMH or by pooling attributed beneficiaries across more than one PCMH as described in Section 233.000.
DMS may add, remove or adjust these exclusions based on new research, empirical evidence, provider experience with select beneficiary populations or inclusion of new payers. DMS will publish such an addition, removal or modification on
www.pavmentinitiative.org/referenceMaterials/Documents/2016PCMHProgramPolicvAdde ndum.pdf.
Eligibility requirements for shared savings for Comprehensive Primary Care (CPC) practices are described in Section 251.000.
Shared savings payments are made to the individual PCMHs which are part of a shared savings entity. These payments are risk- and time- adjusted and prorated based on the number of beneficiaries of each PCMH. These payments are predicated on each PCMH maintaining eligibility for practice support as described in Section 222.000.
Shared savings entities will meet the minimum pool size of 5,000 attributed beneficiaries as described in Section 232.000 in one of three ways:
In the methods B and C listed above, PCMHs have their performance measured together by aggregating performance of the per beneficiary cost of care. In the method B, the quality metrics are tracked for shared savings incentive payments across all the PCMHs in the pool. In the method C, the quality metrics are tracked for shared savings incentive payments on an individual PCMH level. A shared savings entity's configuration (A, B orC) is established during the enrollment period and cannot be changed after the end of the enrollment period.
PCMHs may voluntarily pool for purposes described in Section 233.000 before the end of the enrollment period that precedes the start of the performance period. To pool, the participating practice must email a complete and accurate Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Form (DMS-845) to ARKPCMH@hp.com. View or print the Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Form.You can also download the form from the AHIN provider portal.
The DMS-845 Pooling form must be executed by all PCMHs participating in the pool. Before the end of the enrollment period, PCMHs that are on their own or through pooling do not reach a minimum of 5,000 attributed beneficiaries will be assigned to the default pool. Individual PCMHs whose attribution changes during the performance period will be classified as standalone or default pool members according to their attribution count at the end of the performance period. This exception does not apply to voluntary pools.
Pooling is effective for a single performance period and must be renewed for each subsequent year.
When a PCMH has voluntarily pooled, its performance is measured in the associated shared savings entity throughout the duration of the performance period unless it withdraws from the PCMH program during the performance period. When a PCMH in the voluntary pool withdraws from the PCMH program, any and all PCMHs in the shared savings entity will have their performance measured as if the withdrawn PCMH had never participated in the pool.
Each year, the per beneficiary cost of care performance is aggregated and assessed across a shared savings entity. Per beneficiary cost of care is calculated as the risk- and time-adjusted average of such entity's attributed beneficiaries' total fee-for-service claims (based on the published reimbursement methodology) during the annual performance period, with adjustments and exclusions as defined below.
One hundred percent of the dollar value of care coordination payments is included in the per beneficiary cost of care calculation.
As described in Section 232.000, beneficiaries not counted toward the minimum number of attributed beneficiaries for shared savings incentive payments will be excluded from the calculation of per beneficiary cost of care.
Some costs are excluded from the calculation of per beneficiary cost of care. Each year DMS will announce which costs are excluded at
www.pavmentinitiative.org/referenceMaterials/Documents/2016PCMHProgramPolicvAdde ndum.pdf.
DMS will calculate a historical baseline per beneficiary cost of care for each shared savings entity. This shared savings entity-specific historical baseline will be calculated as a multi-year blended average of each shared savings entity's per beneficiary cost of care.
DMS will calculate benchmark costs for each shared savings entity by applying a 2.6% benchmark trend to the entity's historical baseline per beneficiary cost of care. DMS may reevaluate the value of this benchmark trend if the annual, system-average per beneficiary cost of care growth rate differs significantly from a benchmark, to be specified by DMS. DMS will publish any modification to the benchmark trend at
www.pavmentinitiative.org/referenceMaterials/Documents/2016PCMHProgramPolicvAdde ndum.pdf.
A shared savings entity is eligible to receive a shared savings incentive payment that is the greater of:
If the shared savings entity's per beneficiary cost of care falls below the current performance period medium cost threshold, then the shared savings entity may be eligible for a shared savings incentive payment for absolute performance. The per beneficiary shared savings incentive payment for absolute performance for which the entity may be eligible is calculated as follows: ([medium cost threshold for that performance period] - [per beneficiary cost of care for that performance period]) * [50%].
Shared savings calculations under absolute performance and performance improvements are subject to the following criteria:
These thresholds reflect an annual increase of 1.5% from the base year thresholds (base year medium cost threshold: $1,972; base year high cost threshold: $2,638) and will increase by 1.5% each subsequent year. Adjustments to the thresholds will be posted at
www.paymentinitiative.org/referenceMaterials/Documents/2016PCMHProgramPolicy Addendum.pdf.
www.paymentinitiative.org/referenceMaterials/Documents/2016PCMHProgram PolicyAddendum.pdf.
If participating practices have pooled their attributed beneficiaries together, then shared savings incentive payments will be allocated to those practices based on risk- and time-adjustment and in proportion to the number of attributed beneficiaries that each PCMH contributed to such pool.
Using the provider portal, participating PCMHs must complete and document the activities as announced by DMS at
www.pavmentinitiative.org/referenceMaterials/Documents/2016PCMHProgramPolicvAdde ndum.pdf.The reference point for the deadlines is the first day of the calendar year.
If a PCMH does not meet deadlines and targets for activities tracked for practice support as described in Section 241.000, then the practice must remediate its performance to avoid suspension or termination of practice support.
DMS will verify whether attestation and required documentation was submitted as required by the PCMH program. Failure to comply with this requirement will result in a Notice of Attestation Failure.
DMS will also validate whether attested activities met the PCMH program requirements. Failure to pass validation will result in a Notice of Validation Failure.
PCMHs which received a Notice of Attestation Failure and/or PCMHs which received a Notice of Validation Failure will have 15 calendar days to submit sufficient QIP. Failure to submit sufficient QIP within 15 days of receiving a Notice of Attestation Failure and/or a Notice of Validation Failure will result in suspension or termination of practice support. PCMHs which receive a Notice of Attestation Failure will have 90 days to remediate their performance from the date of the Notice of Attestation Failure. PCMHs which received a Notice of Validation Failure will have 45 days to remediate their performance from the date of the Notice of Validation Failure.
If a PCMH fails to meet the deadlines or targets for activities within the specified remediation time, then DMS will suspend or terminate practice support.
DMS assesses quality metrics tracked for shared savings incentive payments according to the targets announced by DMS at www.pavmentinitiative.org. To receive a shared savings incentive payment, the shared savings entity or PCMH must meet the quality metrics on which the entity or PCMH is assessed and which are published at
www.pavmentinitiative.org/referenceMaterials/Documents/2016PCMHProgramPolicvAdde ndum.pdf.
DMS provides participating PCMH provider reports containing information about their PCMH performance on activities tracked for practice support, quality metrics tracked for shared savings incentive payments and their per beneficiary cost of care via the provider portal.
Providers who have concerns about information included in their reports should send an email to PCMH(S)AFMC.org. The PCMH Quality Assurance Manager will respond to the provider/practice with a review of their inquiry. If the review leads to a discovery that the provider report is inaccurate or does not reflect actual performance, DMS will take the necessary steps to correct the inaccuracies including those that are a result of a systems and/or algorithm error. Providers can also call the APII help desk at 501-301-8311 or 866-322-4698 and by email at ARKPII@HPE.com.
If you disagree with DMS' decision regarding program participation, payment or other adverse action, you have the right to request reconsideration and you have the right to request an administrative appeal.
The Division of Medical Services must receive written request for reconsideration within (30) calendar days of the Date of the adverse action, notice. Send your request to the Director, Division of Medical Services P.O. Box 1437, Slot S401, Little Rock, AR 72203.
The Arkansas Department of Health must receive a written appeals request within (30) calendar days of the date of the adverse action notice, or within (10) calendar days of receiving a reconsideration decision. Send your request to Arkansas Department of Health: Attention: Medicaid Provider Appeals Office, 4815 West Markham Street, Slot 31, Little Rock, AR 72205.
Claim Forms
Red-ink Claim Forms
The following is a list of the red-ink claim forms required by Arkansas Medicaid. The forms below cannot be printed from this manual for use. Information about where to get the forms and links to samples of the forms is available below. To view a sample form, click the form name.
Claim Type | Where To Get Them |
Professional - CMS-1500 | Business Form Supplier |
Institutional - CMS-1450* | Business Form Supplier |
Visual Care - DMS-26-V | 1-800-457-4454 |
Inpatient Crossover - HP-MC-001 | 1-800-457-4454 |
Long Term Care Crossover - HP-MC-002 | 1-800-457-4454 |
Outpatient Crossover - HP-MC-003 | 1-800-457-4454 |
Professional Crossover - HP-MC-004 | 1-800-457-4454 |
* For dates of service after 11/30/07 - ALL HOSPICE PROVIDERS USE ONLY FORM CMS-1450 (formerly UB-04) for billing.
Claim Forms
The following is a list of the non-red-ink claim forms required by Arkansas Medicaid. Information about where to get a supply of the forms and links to samples of the forms is available below. To view a sample form, click the form name.
Claim Type | Where To Get Them |
Alternatives Attendant Care Provider Claim Form - | Client Employer |
AAS-9559 | |
Dental - ADA-J430 | Business Form Supplier |
Arkansas Medicaid Forms
The forms below can be printed from this manual for use.
In order by form name:
Form Name | Form Link |
Acknowledgement of Hysterectomy Information | DMS-2606 |
Address Change Form | DMS-673 |
Adjustment Request Form - Medicaid XIX | HP-AR-004 |
Adverse Effects Form | DMS-2704 |
AFMC Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components | DMS-679A |
Amplification/Assistive Technology Recommendation Form | DMS-686 |
Application for WebRA Hardship Waiver | DMS-7736 |
Approval/Denial Codes for Inpatient Psychiatric Services | DMS-2687 |
Arkansas Early Intervention Infant & Toddler Program Intake/Referral/Application for Services | DDS/FS#0001.a |
Arkansas Medicaid Patient-Centered Medical Home Program Practice Participation Agreement | DMS-844 |
Arkansas Medicaid Patient-Centered Medical Home Program Practice Update/Change Request Form | DMS-801 |
Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Form | DMS-845 |
Arkansas Medicaid Patient-Centered Medical Home Program Practice Withdrawal Form | DMS-846 |
ARKids First Behavioral Health Services Provider Qualification Form | DMS-612 |
Authorization for Automatic Deposit | autodeposit |
Authorization for Payment for Services Provided | MAP-8 |
Certification of Need - Medicaid Inpatient Psychiatric Services for Under Age 21 | DMS-2633 |
Certification of Schools to Provide Comprehensive EPSDT Services | CSPC-EPSDT |
Certification Statement for Abortion | DMS-2698 |
Change of Ownership Information | DMS-0688 |
Child Health Management Services Enrollment Orders | DMS-201 |
Child Health Management Services Discharge Notification Form | DMS-202 |
CHMS Benefit Extension for Diagnosis/Evaluation Procedures | DMS-699A |
CHMS Request for Prior Authorization | DMS-102 |
Claim Correction Request | DMS-2647 |
Consent for Release of Information | DMS-619 |
Contact Lens Prior Authorization Request Form | DMS-0101 |
Contract to Participate in the Arkansas Medical Assistance Program | DMS-653 |
DDTCS Transportation Log | DMS-638 |
DDTCS Transportation Survey | DMS-632 |
Dental Treatment Additional Information | DMS-32-A |
Disclosure of Significant Business Transactions | DMS-689 |
Disproportionate Share Questionnaire | DMS-628 |
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Prescription/Referral For Medically Necessary Services/Items Not Specifically Included in the Medicaid State Plan | DMS-693 |
Early Childhood Special Education Referral Form | ECSE-R |
EPSDT Provider Agreement | DMS-831 |
Explanation of Check Refund | HP-CR-002 |
Gait Analysis Full Body | DMS-647 |
Home Health Certification and Plan of Care | CMS-485 |
Inpatient Psychiatric Medicaid Agency Review Team Transmittal Sheet | DMS-2685 |
Individual Renewal Form for School-Based Audiologists | DMS-7782 |
Lower-Limb Prosthetic Evaluation | DMS-650 |
Lower-Limb Prosthetic Prescription | DMS-651 |
Media Selection/E-Mail Address Change Form | HP-MS-005 |
Medicaid Claim Inquiry Form | HP-CI-003 |
Medicaid Form Request | HP-MFR-001 |
Medical Equipment Request for Prior Authorization & Prescription | DMS-679 |
Medical Transportation and Personal Assistant Verification | DMS-616 |
Mental Health Services Provider Qualification Form for LCSW, LMFT and LPC | DMS-633 |
Notice Of Noncompliance | DMS-635 |
NPI Reporting Form | DMS-683 |
Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries Under Age 21 Prescription/Referral | DMS-640 |
Ownership and Conviction Disclosure | DMS-675 |
Personal Care Assessment and Service Plan | DMS-618 English DMS-618 Spanish |
Practitioner Identification Number Request Form | DMS-7708 |
Prescription & Prior Authorization Request For Nutrition Therapy & Supplies | DMS-2615 |
Primary Care Physician Managed Care Program Referral Form | DMS-2610 |
Primary Care Physician Participation Agreement | DMS-2608 |
Primary Care Physician Selection and Change Form | DMS-2609 |
Procedure Code/NDC Detail Attachment Form | DMS-664 |
Provider Application | DMS-652 |
Provider Communication Form | AAS-9502 |
Provider Data Sharing Agreement - Medicare Parts C & D | DMS-652-A |
Provider Enrollment Application and Contract Package | Application Packet |
Quarterly Monitoring Form | AAS-9506 |
Referral for Audiology Services - School-Based Setting | DMS-7783 |
Referral for Certification of Need Medicaid Inpatient Psychiatric Services for Under Age 21 | DMS-2634 |
Referral for Medical Assistance | DMS-630 |
Request for Appeal | DMS-840 |
Request for Extension of Benefits | DMS-699 |
Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services | DMS-671 |
Request for Extension of Benefits for Medical Supplies for Medicaid Beneficiaries Under Age 21 | DMS-602 |
Request for Molecular Pathology Laboratory Services | DMS-841 |
Request For Orthodontic Treatment | DMS-32-0 |
Request for Private Duty Nursing Services Prior Authorization and Prescription - Initial Request or Recertification | DMS-2692 |
Request for Targeted Case Management Prior Authorization for Beneficiaries Under Age 21 | DMS-601 |
Research Request Form | HP-0288 |
Service Log - Personal Care Delivery and Aides Notes | DMS-873 |
Sterilization Consent Form | DMS-615 English DMS-615 Spanish |
Sterilization Consent Form - Information for Men | PUB-020 |
Sterilization Consent Form - Information for Women | PUB-019 |
Upper-Limb Prosthetic Evaluation | DMS-648 |
Upper-Limb Prosthetic Prescription | DMS-649 |
Vendor Performance Report | Vendorperformreport |
Verification of Medical Services | DMS-2618 |
In order by form number:
AAS-9502 |
AAS-9506 |
AAS-9559 |
Address Change |
Autodeposit |
CMS-485 |
CSPC-EPSDT |
DDS/FS#0001.a |
DMS-0101 |
DMS-0688 |
DMS-102 |
DMS-201 |
DMS-202 |
DMS-2606 |
DMS-2608 |
DMS-2609 |
DMS-2610 |
DMS-2615 |
DMS-2618 |
DMS-2633 |
DMS-2634 |
DMS-2647 |
DMS-2685 |
DMS-2687 |
DMS-2692 |
DMS-2698 |
DMS-2704 |
DMS-32-A |
DMS-32-0 |
DMS-601 |
DMS-602 |
DMS-612 |
DMS-615 English |
DMS-615 Spanish |
DMS-616 |
DMS-618 English |
DMS-618 Spanish |
DMS-619 |
DMS-628 |
DMS-630 |
DMS-632 |
DMS-633 |
DMS-635 |
DMS-638 |
DMS-640 |
DMS-647 |
DMS-648 |
DMS-649 |
DMS-650 |
DMS-651 |
DMS-652 |
DMS-652-A |
DMS-653 |
DMS-664 |
DMS-671 |
DMS-675 |
DMS-673 |
DMS-679 |
DMS-679A |
DMS-683 |
DMS-686 |
DMS-689 |
DMS-693 |
DMS-699 |
DMS-699A |
DMS-7708 |
DMS-7736 |
DMS-7782 |
DMS-7783 |
DMS-801 |
DMS-831 |
DMS-840 |
DMS-841 |
DMS-844 |
DMS-845 |
DMS-846 |
DMS-873 |
ECSE-R |
HP-0288 |
HP-AR-004 |
HP-CI-003 |
HP-CR-002 |
HP-MFR-001 |
HP-MS-005 |
MAP-8 |
Performance Report |
Provider Enrollment Application and Contract Package |
PUB-019 |
PUB-020 |
Arkansas Medicaid Contacts and Links
Click the link to view the information.
American Hospital Association
Americans with Disabilities Act Coordinator
Arkansas Department of Education, Health and Nursing Services Specialist
Arkansas Department of Education, Special Education
Arkansas Department of Finance Administration, Sales and Tax Use Unit
Arkansas Department of Human Services, Division of Aging and Adult Services
Arkansas Department of Human Services, Appeals and Hearings Section
Arkansas Department of Human Services, Division of Behavioral Health Services
Arkansas Department of Human Services, Division of Child Care and Early Childhood Education, Child Care Licensing Unit
Arkansas Department of Human Services, Division of Children and Family Services, Contracts Management Unit
Arkansas Department of Human Services, Children's Services
Arkansas Department of Human Services, Division of County Operations, Customer Assistance Section
Arkansas Department of Human Services, Division of Medical Services
Arkansas DHS, Division of Medical Services Director
Arkansas DHS, Division of Medical Services, Benefit Extension Requests, UR Section
Arkansas DHS, Division of Medical Services, Dental Care Unit
Arkansas DHS, Division of Medical Services, HP Enterprise Services Provider Enrollment Unit
Arkansas DHS, Division of Medical Services, Financial Activities Unit
Arkansas DHS, Division of Medical Services, Hearing Aid Consultant
Arkansas DHS, Division of Medical Services, Medical Assistance Unit
Arkansas DHS, Division of Medical Services, Medical Director for Clinical Affairs
Arkansas DHS, Division of Medical Services, Pharmacy Unit
Arkansas DHS, Division of Medical Services, Program Communications Unit
Arkansas DHS, Division of Medical Services, Program Integrity Unit (PI)
Arkansas DHS, Division of Medical Services, Provider Reimbursement Unit
Arkansas DHS, Division of Medical Services, Third-Party Liability Unit
Arkansas DHS, Division of Medical Services, UR/Home Health Extensions
Arkansas DHS, Division of Medical Services, Utilization Review Section
Arkansas DHS, Division of Medical Services, Visual Care Coordinator
Arkansas Department of Health
Arkansas Department of Health, Health Facility Services
Arkansas Department of Human Services, Accounts Receivable
Arkansas Foundation for Medical Care
Arkansas Foundation for Medical Care, Retrospective Review for Therapy and Prior Authorization for Personal Care for Under Age 21
Arkansas Hospital Association
ARKids First-B
ARKids First-B ID Card Example
Central Child Health Services Office (EPSDT)
ConnectCare Helpline
County Codes
Dental Contractor
HP Enterprise Services Claims Department
HP Enterprise Services EDI Support Center (formerly AEVCS Help Desk)
HP Enterprise Services Inquiry Unit
HP Enterprise Services Manual Order
HP Enterprise Services Provider Assistance Center (PAC)
HP Enterprise Services Supplied Forms
Example of Beneficiary Notification of Denied ARKids First-B Claim
Example of Beneficiary Notification of Denied Medicaid Claim
First Connections Infant & Toddler Program, Developmental Disabilities Services
First Connections Infant & Toddler Program, Developmental Disabilities Services, Appeals
Flow Chart of Intake and Prior Authorization Process For Intervention/Treatment
Health Care Declarations
Immunizations Registry Help Desk
Magellan Pharmacy Call Center
Medicaid ID Card Example
Medicaid Managed Care Services (MMCS)
Medicaid Reimbursement Unit Communications Hotline
Medicaid Tooth Numbering System
National Supplier Clearinghouse
Partners Provider Certification
Primary Care Physician (PCP) Enrollment Voice Response System
Provider Qualifications, Division of Behavioral Health Services
Select Optical
Standard Register
Table of Desirable Weights
UAMS College of Pharmacy Evidence-Based Prescription Drug Program Help Desk
U.S. Government Printing Office
ValueOptions
Vendor Performance Report
ARKANSAS MEDICAID PATIENT-CENTERED MEDICAL HOME PROGRAM PRACTICE UPDATE/CHANGE REQUEST FORM
As a facility involved in the Arkansas Medicaid PCMH program, we understand that changes come quickly and frequently. With that in mind, we always want to make sure that we contact you with any changes and maintain changes which occur in your practice that may affect your participation in the PCMH program. In order to do that, we need your most current contact information including the office leads responsible for updating this information as well as changes to your physician enrollment roster. To make sure we can best assist you in your participation with this program, please update the following information below as necessary.
Office lead for Practice Transformation: ________________________________________________________________
Title: ________________________________________________________________
Email: ________________________________________________________________
Signature: ________________________________________________________________
Office lead for Care Coordination: ________________________________________________________________
Title: ________________________________________________________________
Email: ________________________________________________________________
Signature: ________________________________________________________________
ADD PHYSICIAN
Please list the required information for the physicians you wish to enroll under your practice:
NOTE: The only physicians who need to be added to the PCMH enrollment are those who recently joined your practice. For this reason, please include the date the physician joined.
Individual Medicaid Provider ID: ________________________________________________________________
NPI: ________________________________________________________________
Date joined: ________________________________________________________________
Signature: ________________________________________________________________
Individual Medicaid Provider ID: ________________________________________________________________
NPI: ________________________________________________________________
Date joined: ________________________________________________________________
Signature: ________________________________________________________________
Individual Medicaid Provider ID: ________________________________________________________________
NPI: ________________________________________________________________
Date joined: ________________________________________________________________
Signature: ________________________________________________________________
Please add additional pages as necessary to list all physicians who are part of your practice.
_________________________ ______________________ _________________
For the practice Title Date
Phone number: __________________
DMS-801 (1/16)
Email Address: __________________
WITHDRAW PHYSICIAN
Please list the required information for the physicians you wish to withdraw from your practice:
NOTE: The only physicians who need to be removed from the PCMH enrollment are those who recently left your practice. For this reason, please include the date the physician left.
Individual Medicaid Provider ID: ________________________________________________________________
NPI: ________________________________________________________________
Date left: ________________________________________________________________
Individual Medicaid Provider ID: ________________________________________________________________
NPI: ________________________________________________________________
Date left: ________________________________________________________________
Individual Medicaid Provider ID: ________________________________________________________________
NPI: ________________________________________________________________
Date left: ________________________________________________________________
Individual Medicaid Provider ID: ________________________________________________________________
NPI: ________________________________________________________________
Date left: ________________________________________________________________
Please add additional pages as necessary to list all physicians who are part of your practice.
_________________________ ______________________ _________________
For the practice Title Date
Phone number: __________________
Email Address: __________________
ARKANSAS MEDICAID PATIENT-CENTERED MEDICAL HOME PROGRAM PRACTICE PARTICIPATION AGREEMENT
This agreement is made and entered into between ___________________________________________ ,
(Please print, stamp or type practice name)
hereinafter called Practice, and the Arkansas Division of Medical Services, hereinafter called Department. This agreement supplements and is controlled by the terms of the parties' "Contract to Participate in the Arkansas Medical Assistance Program Administered by the Division of Medical Services Under Title XIX (Medicaid)" (Form DMS-653, hereinafter called Provider Enrollment Agreement), and any successor agreement.
Practice, in consideration of the mutual covenants set forth herein and in the Provider Enrollment Agreement, requests to be a Medicaid enrolled Patient-Centered Medical Home (PCMH) participating practice in compliance with all pertinent Medicaid policies, regulations, and State Plan standards.
This agreement may be terminated or renewed in accordance with the following provisions:
If the Practice is a legal entity other than a person, the person signing this Practice Participation Agreement on behalf of the Practice warrants that he/she has legal authority to bind the Practice. The signature of the Practice or the person with the legal authority to bind the Practice on this contract certifies the Practice understands that payment and satisfaction of these claims will be made from Federal and State funds, and that any false claims, statements, or documents, or concealment of material fact, may be prosecuted under applicable Federal and State laws.
Please indicate your office lead(s) for practice transformation and care coordination. These individuals will serve as the administrative points-of-contact for the program:
Office lead for Practice Transformation: _________________________________________________________________
Title: _________________________________________________________________
Email: _________________________________________________________________
Signature: _________________________________________________________________
Office lead for Care Coordination: _________________________________________________________________
Title: _________________________________________________________________
Email: _________________________________________________________________
Signature: _________________________________________________________________
Please indicate the Medicaid Billing ID Number to which care coordination and shared savings payments will be made for the providers named below:
____________________________
Medicaid Billing ID Number
DMS-844 (1/16)
______________________________________ ________________________________________ _________________
For the practice Title Date
Phone number: ______________________
Email address: _______________________
______________________________________ ________________________________________ _________________
Division of Medical Services Signature Title Date
Please list the physicians who are part of your practice:
Individual Medicaid Provider ID: ______________________________________________________________
NPI: ______________________________________________________________
Signature: ______________________________________________________________
Individual Medicaid Provider ID: ______________________________________________________________
NPI: ______________________________________________________________
Signature: ______________________________________________________________
Individual Medicaid Provider ID: ______________________________________________________________
NPI: ______________________________________________________________
Signature: ______________________________________________________________
Individual Medicaid Provider ID: ______________________________________________________________
NPI: ______________________________________________________________
Signature: ______________________________________________________________
Please add additional pages as necessary to list all physicians who are part of your practice. The practice must update DHS of changes to the list of physicians who are part of your practice in writing within 30 days. If such change includes the addition of a physician to your practice, such notice must include the information listed above.
DMS-844 (1/16)
ARKANSAS MEDICAID PATIENT-CENTERED MEDICAL HOME PROGRAM POOLING REQUEST FORM
Practices wishing to pool attributed beneficiaries for purposes of the PCMH program, as described in the pooling section of the Arkansas Medicaid PCMH provider manual, must submit the pooling request form.
First Practice
(Please print, stamp or type practice name)
________________________________
Second Practice
(Please print, stamp or type practice name)
________________________________
Third Practice
(Please print, stamp or type practice name)
________________________________
DMS-845 (1/16)
Fourth Practice
(Please print, stamp or type practice name)
________________________________
Pooling Request
By signing this form, ________________________________________ and
(Please print, stamp or type first practice name)
_______________________________________ and
(Please print, stamp or type second practice name)
_______________________________________ and
(Please print, stamp or type third practice name)
_______________________________________
(Please print, stamp or type fourth practice name)
hereafter called the practices, are requesting to pool their attributed beneficiaries as a common shared savings entity for purposes of the Patient-Centered Medical Home (PCMH) program as described in the Arkansas Medicaid PCMH provider manual. The practices request to have their performance measured together by aggregating performance across the practices. Specifically, performance (both for Per Beneficiary Cost of Care and Shared Savings Quality Metrics as described in the Arkansas Medicaid PCMH provider manual) is measured across the beneficiaries attributed to the practices identified above as a shared savings entity. The practices' attributed beneficiaries shall remain pooled in a shared savings entity only for the performance period in the next calendar year. In order to remain pooled, the practices must resubmit this section of the practice participation agreement annually.
___________________________________ ________________________________________ _________________
For the first practice Title Date
Practice name: ______________________
Phone number: ______________________
Email address: ______________________
DMS-845 (1/16)
___________________________________ ________________________________________ _________________
For the second practice Title Date
Practice name: ______________________
Phone number: ______________________
Email address: ______________________
___________________________________ ________________________________________ _________________
For the third practice Title Date
Practice name: ______________________
Phone number: ______________________
Email address: ______________________
___________________________________ ________________________________________ _________________
For the fourth practice Title Date
Practice name: ______________________
Phone number: ______________________
Email address: ______________________
For the performance period beginning in 2015:
______________________________________ ________________________________________ _________________
Division of Medical Services Signature Title Date
ARKANSAS MEDICAID PATIENT-CENTERED MEDICAL HOME PROGRAM PRACTICE WITHDRAWAL FORM
(Please print, stamp or type practice name)
________________________________
Withdrawal Statement
By signing this withdrawal form, _____________________________________ , hereafter called practice, is requesting to
(Please print, stamp or type practice name)
withdraw from the Arkansas Medicaid Patient-Centered Medical Home program, understanding that all potential practice support per member per month payments and shared savings payments under the Patient-Centered Medical Home program will cease immediately. This withdrawal form serves to terminate the Patient-Centered Medical Home contract that exists between Arkansas Medicaid and the practice. The practice acknowledges that the Arkansas Medicaid program may reconcile any outstanding overpayment through reduction of future Medicaid fee-for-service reimbursement.
___________________________________ ________________________________________ _________________
For the practice Title Date
Phone number: ______________________
Email address: ______________________
______________________________________ ________________________________________ __________________
Division of Medical Services Signature Title Date
DMS-846 (1/16)
016.06.15 Ark. Code R. § 017