DIVISION OF MEDICAL SERVICES MEDICAL ASSISTANCE PROGRAM PROVIDER APPLICATION

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 Gainwell Technologies 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 DMS-652 (R 1/21) FOR OFFICE USE ONLY Pending: Computer: OK to Key: Keyed: Maintenance Checked: Provider ID Number: Taxonomy Code: Specialty Code: Provider Type: Effective Date: 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 NOTE: Item or must be completed, BUT NOT BOTH Last Name (3) First Name M.I Title 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 or 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 = = = = = = = = = = Individual Practitioner (i.e., physician; dentist; a licensed, registered or certified practitioner) Sole Proprietorship (This includes individually owned businesses) Government Owned Business Corporation, for profit Business Corporation, non-profit * copy of Tax Form 501 (c) (3) must accompany this application Private, for profit Private, non-profit * copy of Tax Form 501 (c) (3) must accompany this application Partnership Trust Chain * NOTE: IF THE TAX FORM IS NOT ATTACHED THE APPLICATION WILL BE DENIED DMS-652 (R 1/21) (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 (A) Enter the applicant's service location address, include suite number if applicable THIS FIELD IS MANDATORY _ (B) 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 (D) State _ Zip Code+4 Telephone Number - enter the area code and telephone number of the location in which the services are provided _ Area Code Telephone Number (E) Fax Number – enter the area code and fax number of the location in which the services are provided _ Area Code Fax Number DMS-652 (R 1/21) (8) Billing Street Address (A) 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 (B) 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 (medicaid.mmis.arkansas.gov) The website is updated weekly Email address: When providing your email address, please 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 ‘gainwelltechnologies.com’ You may have to instruct your network administrator or email provider to accept emails from ‘gainwelltechnologies.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 DMS-652 (R 1/21) (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 Arkansas Ashley Baxter Benton Boone Bradley Calhoun Carroll Chicot Clark Clay Cleburne Cleveland Columbia Conway Craighead Crawford Crittenden Cross Dallas Desha Drew Faulkner Franklin Fulton County Code 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 State Louisiana Missouri Mississippi County Code 91 92 93 DMS-652 (R 1/21) County Garland Grant Greene Hempstead Hot Spring Howard Independence Izard Jackson Jefferson Johnson Lafayette Lawrence Lee Lincoln Little River Logan Lonoke Madison Marion Miller Mississippi Monroe Montgomery Nevada County Code 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 County Code 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 County Newton Ouachita Perry Phillips Pike Poinsett Polk Pope Prairie Pulaski Randolph Saline Scott Searcy Sebastian Sevier Sharp St Francis Stone Union Van Buren Washington White Woodruff Yell State Oklahoma Tennessee County Code 94 95 County State Code Texas 96 All other states 97 (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 N3 N4 N6 N7 N8 N9 N0 03 A4 AA AV AW AX AZ AH AL AP 64 C1 C2 06 C4 CF 35 C8 04 C9 C3 HA HB HC HE H7 HG H9 IC HF N5 V2 V1 V0 X5 V6 07 V3 DR V5 CN CO E4 E5 E6 E7 EC E8 E9 EA EB E1 DMS-652 (R 1/21) Category Description Advanced Practice Nurse – Pediatrics Advanced Practice Nurse – Women’s Health Advanced Practice Nurse – Family Advanced Practice Nurse – Adult/Gerontological Advanced Practice Nurse – Psychiatric Mental Health Advanced Practice Nurse – Acute Care Advanced Practice Nurse – Nurse Practitioner - Other Allergy/Immunology Ambulatory Surgical Center Adolescent Medicine Anesthesiology Autism Intensive Intervention Provider Autism Consultant Autism Lead/Line Therapist Autism Clinical Service Specialist Living Choices Assisted Living Agency Living Choices Assisted Living Facility—Direct Services Provider Living Choices Assisted Living Pharmacist Consultant Audiologist Cancer Screen (Health Dept Only) Cancer Treatment (Health Dept Only) Cardiovascular Disease Child Health Management Services Child Health Management Services - Foster Care Chiropractor Communicable Diseases (Health Dept Only) Community Support Systems Provider Base Community Support Systems Provider Enhanced CRNA ACS Waiver Environmental Modifications/Adaptive Equipment ACS Waiver Specialized Medical Supplies ACS Waiver Case Management/Transitional Case Management/Community Transition Services ACS Waiver Supported Employment ACS Waiver Supportive Living/Respite/Supplemental Support ACS Waiver Crisis Intervention ACS Waiver Consultation Services IndependentChoices ACS Waiver Organized HealthCare Delivery System DDS Non-Medicaid Dental Dental Clinic (Health Dept Only) Dental - Mobile Dental Facility Dental - Oral Surgeon Dental - Orthodontia Dermatology Developmental Day Treatment Center Developmental Rehabilitation Services Domiciliary Care DYS/TCM Group DYS/TCM Performing ARChoices in Homecare Waiver - Environmental Modifications ARChoices in Homecare Waiver - Adult Family Homes ARChoices in Homecare Waiver - Attendant Care ARChoices in Homecare Waiver - Home delivered hot meals ARChoices in Homecare Waiver - Home delivered frozen meals ARChoices in Homecare Waiver - Personal emergency response systems ARChoices in Homecare Waiver - Adult day care ARChoices in Homecare Waiver - Adult day health care ARChoices in Homecare Waiver - Respite care Emergency Medicine (10) Provider Category (Continued) Code E2 E3 F1 08 F2 10 01 38 16 H1 H2 H5 H3 H6 A5 W6 W7 CH IH IS P7 P8 R7 HN H4 V8 69 55 W3 WA WB WC W4 W9 W5 11 L1 M1 M4 WI W2 R5 62 XX N1 39 13 NI N2 N3 N4 N6 N7 RK X1 18 X2 X4 X6 12 X7 X8 X9 22 37 DMS-652 (R 1/21) Category Description Endocrinology Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Family Planning Family Practice Federally Qualified Health Center Gastroenterology General Practice Geriatrics Gynecology - Obstetrics Hearing Aid Dealer Hematology Hemodialysis Home Health Hospice Hospital - AR State Operating Teaching Hospital Hospital - Inpatient Hospital - Outpatient Hospital - Critical Access Hospital - Indian Health Services Hospital - Indian Health Services Freestanding Hospital - Pediatric Inpatient Hospital - Pediatric Outpatient Hospital - Rural Inpatient Hyperalimentation Enteral Nutrition - Sole Source Hyperalimentation Parenteral Nutrition - Sole Source Immunization (Health Dept Only) Independent Lab Infectious Diseases Inpatient Psychiatric - under 21 Inpatient Psychiatric - Residential Treatment Unit within Inpatient Psychiatric Hospital Inpatient Psychiatric - Residential Treatment Center Inpatient Psychiatric - Sexual Offenders Program Intermediate Care Facility Intermediate Care Facility - Infant Infirmaries Intermediate Care Facility - Mentally Retarded Internal Medicine Laryngology Maternity Clinic (Health Dept Only) Medicare/Medicaid Crossover Only Mental Health Practitioner - Licensed Certified Social Worker Mental Health Practitioner - Licensed Professional Counselor Mental Health Practitioner - Licensed Marriage and Family Therapist Mental Health Practitioner - Psychologist Mental Health Practitioner – Licensed Psychologist Examiner-Independent Neonatology Nephrology Neurology Nuclear Medicine Nurse Midwife Nurse Practitioner - Pediatric Nurse Practitioner - OB/GYN Nurse Practitioner - Family Practice Nurse Practitioner - Gerontological Offsite Intervention Service - Outpatient Mental and Behavioral Health (ARKids ONLY) Oncology Ophthalmology Optical Dispensing Contractor Optometrist Orthopedic Osteopathy - Manipulative Therapy Osteopathy - Radiation Therapy Otology Otorhinolaryngology Pathology Pediatrics (10) Provider Category (Continued) Code P1 PA PD PE PG PH R3 PS P2 PC PM PN PR PV P3 48 63 P6 PF 28 P4 V4 Z1 26 P5 29 R9 RA 30 31 R6 RC R1 RJ RL CR R4 R2 R8 S7 S8 S9 SA SB VV SO S5 W8 S6 S1 S2 O2 14 20 53 54 24 33 S4 C5 C6 C7 CM T6 DMS-652 (R 1/21) Category Description Personal Care Services Personal Care Services / Area Agency on Aging Personal Care Services / Developmental Disability Services Personal Care Services / Week-end Personal Care Services / Level I Assisted Living Facility Personal Care Services / Level II Assisted Living Facility Personal Care Services / Residential Care Facility Personal Care Services: Public School or Education Service Cooperative Pharmacy Independent Pharmacy - Chain Pharmacy - Compounding Pharmacy - Home Infusion Pharmacy - Long Term Care / Closed Door Pharmacy - Administrated Vaccines Physical Medicine Podiatrist Portable X-ray Equipment Private Duty Nursing Private Duty Nursing: Public School or Education Service Cooperative Proctology Prosthetic Devices Prosthetic - Durable Medical Equipment/Oxygen Prosthetic - Orthotic Appliances Psychiatry Psychiatry - Child Pulmonary Diseases Radiation Therapy - Complete Radiation Therapy - Technical Radiology - Diagnostic Radiology - Therapeutic Rehabilitative Services for Persons with Mental Illness Rehabilitative Services for Persons with Physical Disabilities Rehabilitative Hospital Rehabilitative Services for Youth and Children DCFS Rehabilitative Services for Youth and Children DYS Respite Care – Children’s Medical Services Rheumatology Rural Health Clinic - Provider Based Rural Health Clinic - Independent Freestanding School Based Health Clinic - Child Health Services School Based Health Clinic - Hearing Screener School Based Health Clinic - Vision Screener School Based Health Clinic - Vision & Hearing Screener School Based Audiology School Based Mental Health Clinic School District Outreach for ARKids Skilled Nursing Facility Skilled Nursing Facility - Special Services SNF Hospital Distinct Part Bed Surgery - Cardio Surgery - Colon & Rectal Surgery - General Surgery - Neurological Surgery - Orthopedic Surgery - Pediatric Surgery - Oncology Surgery - Plastic & Reconstructive Surgery - Thoracic Surgery - Vascular Targeted Case Management - Ages 60 and Older Targeted Case Management - Ages 00 - 20 Targeted Case Management - Ages 21 - 59 Targeted Case Management - Developmental Disabilities Certification - Ages 00 - 20 Therapy - Occupational (10) Provider Category (Continued) Code T1 T2 TO TP TS A1 A2 A6 A7 TA TB TD TC TH 34 V7 (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 fields 12 and 13 unless the entry is a Please check the appropriate code (12) Category Description Therapy - Physical Therapy - Speech Pathologist Therapy - Occupational Assistant Therapy - Physical Assistant Therapy - Speech Pathologist Assistant Transportation - Ambulance, Emergency Transportation - Ambulance, Non-emergency Transportation - Advanced Life Support with EKG Transportation - Advanced Life Support without EKG Transportation - Air Ambulance/Helicopter Transportation - Air Ambulance/Fixed Wing Transportation - Broker Transportation - Non-Emergency Tuberculosis (Health Dept Only) Urology Ventilator Equipment = = = = = = Mental Health Home Health CRNA Nursing Home Other Non-applicable [ [ [ [ [ [ ] ] ] ] ] ] 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 _ _ _ _ _ _ _ _ _ DMS-652 (R 1/21) (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 _ _ _ _ _ _ _ _ _ _ DMS-652 (R 1/21) Ownership and Conviction Disclosure DHS Division of Medical Services, Title XIX (Medicaid) [As required by 42 C.F.R §455, Subpart B: Disclosure of Information by Providers and Fiscal Agents] Yes _ No _ If yes, print name, address and Tax ID Number and amount of % of interest they own Name Complete Primary Address and PO Box Address with Each Business Location % of Interest Tax ID Number List the name, address, date of birth, and complete Social Security Number for any person who is a managing employee of the named entity For larger corporations having more than managing employees or board members, please use next page (4)* Name Address Date of Birth Complete Social Security Number List any person who has a direct or indirect ownership or control interest in the named entity, or is an agent, or managing employee of the named entity who has been convicted of a criminal offense related to that person’s involvement in any program under Medicaid, Medicare, or Title XX programs in any state: Name Offense List names of persons or entities with direct/indirect ownership or control interest in the named entity, or is an agent or managing employee of the named entity who, as listed in DHS Policy 1088 (Participant Exclusion Rule), has been found guilty, or pled guilty or nolo contendere, to any crime related to: (1) obtaining, attempting to obtain, or performing a public or private contract or subcontract, (2) embezzlement, theft, forgery, bribery, falsification or destruction of records, any form of fraud, receipt of stolen property, or any other offense indicating moral turpitude or a lack of business integrity or honesty, (3) dangerous drugs, controlled substances, or other drug-related offenses when the offense is a felony, (4) federal antitrust statutes, (5) the submission of bids or proposals, (6) any physical or sexual abuse or neglect when the offense is a felony Name Offense Ownership and Conviction Disclosure DHS Division of Medical Services, Title XIX (Medicaid) [As required by 42 C.F.R §455, Subpart B: Disclosure of Information by Providers and Fiscal Agents] Name Offense *Use this sheet for multiple business managers/owners or board members Name Address Date of Birth Complete Social Security Number Ownership and Conviction Disclosure DHS Division of Medical Services, Title XIX (Medicaid) [As required by 42 C.F.R §455, Subpart B: Disclosure of Information by Providers and Fiscal Agents] Provider Statement: “By signing this form, I certify that the information provided on this form is true and correct I will notify the Division of Medical Services Medicaid Provider Enrollment Unit if any information changes I will comply with all aspects of this disclosure form By completing and signing this form, I give consent for the information contained herein to be disclosed to the Department of Health and Human Services or any other appropriate governmental agencies, including the Office of Homeland Security.” Name: (Print or Type) Title: _ (Print or Type) Signature: _ Date: _ Disclosure of Significant Business Transactions DHS Division of Medical Services, Title XIX (Medicaid) [As required by 42 C.F.R §455, subpart B: Disclosure of Information by Providers and Fiscal Agents] IMPORTANT Read ALL instructions and definitions contained on this form and use the information as a reference while completing the Significant Business Transactions Disclosure Form Completion and submission of this form is a condition of participation in the Medicaid Program and is a condition of approval or renewal of a provider agreement between the disclosing entity and the Division of Medical Services Full, complete and accurate disclosure of ownership and business transaction information is required Upon request, the provider must furnish all records described in the provider contract within thirty-five (35) days of the date on a request by the Department, the Medicaid Fraud Control Unit, the Arkansas Office of the Medicaid Inspector General, or the U.S Secretary of the Department of Health and Human Services or a designated agent or representative of any entity entitled to those records, full and complete information about: 1) The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and 2) Any significant business transaction between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request Full, complete and accurate disclosure of ownership and financial interests is required Failure to submit requested information may result in a refusal to enter into a provider agreement or contract, or in termination of existing provider agreements INSTRUCTIONS FOR COMPLETING DISCLOSURE FORM Answer all questions as of the current date If additional space is needed, please attach the information at the end of the application for new enrollments, or attach to the form for updated information from existing providers, before returning to the Medicaid Provider Enrollment Unit DEFINITIONS Provider: a named person or entity that furnishes, or arranges for furnishing health related services for which it claims payment under the Medicaid Program Disclosing entity: a Medicaid provider (other than an individual practitioner or group of practitioners), or a fiscal agent Subcontractor: (1) an individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of furnishing health related services; or (2) an individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease to obtain space, supplies, equipment, or services provided under the Medicaid agreement Additionally, if the accrediting agency prohibits subcontracting, sub-leasing or lending its accreditation to another organization, Arkansas Medicaid will follow the restrictions set forth by the accrediting agency Supplier: an individual, agency, or organization from which a provider purchases goods or services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical firm) Wholly owned supplier: a supplier whose total ownership interest is held by a provider or by a person/persons or other entity with an ownership or control interest in a provider DMS-689 (8/14) Page of Disclosure of Significant Business Transactions DHS Division of Medical Services, Title XIX (Medicaid) [As required by 42 C.F.R §455, subpart B: Disclosure of Information by Providers and Fiscal Agents] Significant business transaction: any business transaction or series of related transactions that, during any one fiscal year, exceeds either $25,000 or percent of a provider’s total operating expenses DISCLOSURE OF SIGNIFICANT BUSINESS TRANSACTIONS Submit full, accurate and complete disclosure concerning the following information: 1) Ownership of any subcontractor with whom the named entity has had business transactions totaling more than $25,000 during the last 12 months (12-month period ending as of the date on this application) _ _ _ _ _ _ 2) Any significant business transaction between the named entity and any wholly owned supplier in the last years (5-year period ending as of the date of this application) _ _ _ _ 3) Any significant business transaction between the named entity and any subcontractor in the last years (5-year period ending as of the date of this application) _ _ _ _ Beginning on the effective date of enrollment in the Arkansas Medicaid Program, full, accurate and complete disclosure shall be submitted concerning any significant business transaction that occurs between the named entity and any subcontractor or wholly owned supplier This information shall be submitted within 35 days of the date the transaction takes place Provider Statement: “By signing this form, I certify that the information provided on this form is true and correct I will notify the Division of Medical Services Medicaid Provider Enrollment Unit if any information changes I will comply with all aspects of this disclosure form By completing and signing this form, I give consent for the information contained herein to be disclosed to the Department of Health and Human Services or any other appropriate governmental agencies, including the Office of Homeland Security.” Name: (Print or Type) Title: _ (Print or Type) Signature: _ Date: _ DMS-689 (8/14) Page of 2 Disclosure of Significant Business Transactions DHS Division of Medical Services, Title XIX (Medicaid) [As required by 42 C.F.R §455, subpart B: Disclosure of Information by Providers and Fiscal Agents] DMS-689 (8/14) Page of CONTRACT TO PARTICIPATE IN THE ARKANSAS MEDICAL ASSISTANCE PROGRAM ADMINISTERED BY THE DIVISION OF MEDICAL SERVICES UNDER TITLE XIX (MEDICAID) INSTRUCTIONS Please ensure that the provider name on the front page of the contract is identical to that listed in item #2 or item #3 of the application If these two names not match, your enrollment will be denied and the enrollment packet will be returned DMS-653 (R 8/14) Page of CONTRACT TO PARTICIPATE IN THE ARKANSAS MEDICAL ASSISTANCE PROGRAM ADMINISTERED BY THE DIVISION OF MEDICAL SERVICES TITLE XIX (MEDICAID) The following agreement is entered into between _, hereinafter called Provider, and the Arkansas Department of Human Services, hereafter called Department: I Provider, in consideration of the covenants therein, agrees: A To keep records in accordance with generally accepted standards for the type of business and the healthcare services provided, related to services provided to individuals receiving assistance under the State Plan and billing for such services B To make available and, upon request, furnish all records described above to the Department, the Medicaid Fraud Control Unit of the Arkansas Office of the Attorney General, the U.S Secretary of the Department of Health and Human Services or a designated agent or representative of any entity entitled to records For all Medicaid beneficiaries, these records include, but are not limited to those records which are defined in Section "A" of this contract For clients who are not Medicaid beneficiaries, the records that must be furnished are financial records of charges billed to non-Medicaid insurance to ensure that charges billed to Medicaid not exceed charges billed to non-Medicaid insurance 1) In connection with this contract each party hereto will receive certain confidential information relating to the other party For purposes of this contract, any information furnished or made available to one party relating to the financial condition, results of operation, business, customers, properties, assets, liabilities or information relating to the financial condition relating to beneficiaries and providers, including but not limited to protected health information as defined by the Privacy Rule promulgated pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, is collectively referred to as “Confidential Information." 2) The contract shall safeguard the use and disclosure of information concerning applicants for or beneficiaries of Title XIX services in accordance with 42 CFR Part 431, Subpart F, and shall comply with 45 CFR Parts 160 and 164 and shall restrict access to and disclosure of such information in compliance with federal and state laws and regulations.“ C To make available and, upon request, furnish all records described above within thirty-five (35) days of the date on a request by the Department, the Medicaid Fraud Control Unit, the Arkansas Office of the Medicaid Inspector General, or the U.S Secretary of the Department of Health and Human Services or a designated agent or representative of any entity entitled to those records, full and complete information about: 1) The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and 2) Any significant business transaction between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request D To accept assignment under Title XVIII (Medicare) in order to receive payment under Title XIX (Medicaid) for any applicable deductible or coinsurance that may be due and payable under Title XIX (Medicaid) E To bill Medicaid only after a service has been provided, or as otherwise specified in the appropriate Arkansas Medicaid Provider Manual, Official Notice, or Remittance Advice message F To accept payment from Medicaid as payment in full for a covered service, and to make no additional charges to the beneficiary or accept any additional payment from the beneficiary except cost share (copay or deductible amounts) established by the Medicaid Program G To take assignment and file claims with third party sources (medical or liability insurance, etc.), and if third party payment is made to the Provider, to reimburse Medicaid up to the amount Medicaid paid for the services; to make no claims against third party sources for services for which a claim has been submitted to Medicaid; and to notify Medicaid of the identity of each third party source discovered after submission of a claim or claims to Medicaid H To make no charge to a beneficiary for a claim or a portion of a claim when a determination that the service was not medically necessary is made based on the professional opinion of a peer reviewer; DMS-653 (R 8/14) Page of except that such charge may be made to the beneficiary when he/she has requested the service and has prior knowledge that he/she will be responsible for the cost of such service; and to reimburse the Division of Medical Services for all monies paid for claims for services that later were determined "not medically necessary." I To provide all services without discrimination on the grounds of race, color, national origin, or physical or mental disability within the provisions of Title VI of the Federal Civil Rights Act, Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 J To accept all changes legally made in the Program, and recognize and abide by such changes upon being notified by the Medicaid Program in the form of an update to, or an Official Notice/Remittance Advice Message pertaining to, the appropriate Arkansas Medicaid Provider Manual K That the Department has furnished the Provider with a copy of the Arkansas Medicaid Provider Manual containing the rules, regulations and procedures pertaining to his/her profession The Provider agrees that the terms and conditions contained therein shall be a part of this contract if the same were set out verbatim herein The Provider states that he/she is currently licensed to practice in Arkansas or within the State where services were rendered and agrees to promptly notify the Department if his/her license is revoked or suspended The Provider acknowledges by signature on this contract that he/she has received a copy of the appropriate Arkansas Medicaid Provider Manual L To conform to all Medicaid requirements covered in Federal or State laws, regulations or manuals M To certify by original signature within 48 hours of claims being submitted by an electronic media, a claim count and dollar amount billed, that the information on the claims submitted is true, accurate and complete The Provider agrees to maintain this certification as a matter of record for all claims submitted electronically, by any media N To notify the Department before any change of ownership or operating status Upon change of ownership or operating status the successor owner or operator shall, as a condition of assumption of this agreement, hold the Department harmless for any rate or payment increases, decreases, or adjustments without respect to whether the increase, decrease, or adjustment relates to services delivered before the change in ownership or operating status O FOR HOSPITALS ONLY To understand that the Quality Improvement Organization (Arkansas Foundation for Medical Care, Inc.) is responsible for the review of Medicaid admissions to inpatient hospitals, specifically for length of stay purposes, medical necessity and as otherwise specified in the Memorandum of Understanding between the individual hospital and Arkansas Foundation for Medical Care, Inc II III The Department, in consideration of the material benefits and the covenants and undertakings of the Provider, agrees as follows: A To make payment to the above named Provider for the appropriate Medicaid covered services provided to eligible Medicaid beneficiaries in accordance with the applicable Medicaid reimbursement schedule in effect for the dates of service, and in accordance with the manual of rules, regulations and procedures that is a part of this contract B To notify the above named Provider of applicable changes in Medicaid rules and regulations as they occur C To safeguard the confidentiality of any medical records received by the Department or its fiscal intermediary, as specified in Federal and State regulations This contract may be terminated or renewed in accordance with the following provisions: A This contract may be voluntarily terminated by either party by giving thirty (30) days written notice to the other party without cause and/or convenience of either party; B This contract will be automatically renewed for one year on July of each year if neither party gives notice requesting termination; C This contract may be terminated immediately by the Department for the following reasons: DMS-653 (R 8/14) Page of 1) 2) 3) 4) Returned mail Death of provider Change of ownership Or other reason for which a sanction may be issued as set forth under the applicable Medicaid Provider Manual If the Provider is a legal entity other than a person, the person signing this Provider Contract on behalf of the Provider warrants that he/she has legal authority to bind the Provider The signature of the Provider or the person with the legal authority to bind the Provider on this contract certifies the Provider 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 Provider Name: (As inscribed on previous page of contract) Provider By: (Signature Required) Name: (Typed or Printed Name Required) Title: (Required) Date: _ (Required) DMS-653 (R 8/14) Page of Provider Enrollment By: (Signature) Name: (Typed Name) Title: Date: _ Effective Date of Contract: DATA SHARING AGREEMENT Between The Division of Medical Services Arkansas Medicaid and Insurance or Managed Care Plan Providing Medicare Part C (“Medicare Advantage”) and/or Part D Services WITNESSETH: Based upon the following recitals, the Division of Medical Services and (hereinafter referred to as “Medicare Plan”), FEI # , enter into this data sharing agreement ARTICLE I PURPOSE The Centers for Medicare and Medicaid Services (CMS) has issued correspondence to Medicare Plans on the policies and procedures for initiating corrections to CMS’ lowincome subsidy data for plan enrollees for whom the plan has documentation about their Arkansas Medicaid eligibility or residence in an institution under a Medicaidcovered stay CMS further has provided guidance for Medicare Advantage Special Needs Plans that cover individuals eligible for both Medicare and Medicaid, requiring such plans to verify eligibility through, among other means, a systems query to a State Medicaid eligibility data system The purpose of this data sharing agreement is to provide the “best available evidence” (BAE) of Medicaid eligibility to the Medicare Plans through access to the Arkansas Medicaid Management Information System (MMIS), while protecting the confidentiality of the data which is transferred ARTICLE II THE PARTIES 2.0 Division of Medical Services a) Division of Medical Services (DMS) states that it is the single state agency that administers the Arkansas Medicaid Program b) Division of Medical Services has authority to enter into this Agreement c) Division of Medical Services states that its mailing address for purposes of this Agreement is as follows: Gainwell Technologies Provider Enrollment P O Box 8105 Little Rock, AR 72203-8105 2.1 MEDICARE PLAN DMS-652-A 10/08 a) The Medicare Plan provider states that it has authority to enter into this Agreement pursuant to its contractual arrangement with the CMS for the purpose of determining dual eligibility of persons qualifying for the Medicare Advantage and/or Medicare Part D prescription drug program b) The Medicare Plan provider states that its mailing address for purposes of this Agreement is as follows: Company Name: Attention: Address: City, State, Zip: ARTICLE III TERMS 3.0 MODIFICATIONS This Agreement contains all the agreements of the parties and no oral representation by either party is binding Any modifications to this Agreement must be in writing and signed by both parties prior to the effective date of the modification 3.1 ASSIGNMENT Neither party shall assign or transfer any rights or obligations under this Agreement without the prior written consent of the other party ARTICLE IV SCOPE OF WORK – DATA SHARING 4.0 The Division of Medical Services shall allow the Medicare Plan to enroll in the Arkansas Medicaid Program by completing a Provider Enrollment application This application can be accessed through the Arkansas Medicaid Website at https://medicaid.mmis.arkansas.gov/, or by contacting the Provider Enrollment Unit 4.1 The Medicare Plan will receive a welcome letter containing a provider number, and an effective date which will allow the Medicare Plan access to verify client eligibility The Medicare Plan will not submit claims for processing 4.2 The Medicare Plan will pay the fee of ten cents per electronic eligibility verification transaction 4.3 The Medicare Plan will receive a paper Remittance Advice weekly of the number of eligibility verifications conducted and the dollar amount owed 4.4 The Medicare Plan will be invoiced quarterly for the electronic verification transactions submitted This will balance to the sum of all Remittance Advices received for the quarter ARTICLE V CONFIDENTIALITY, PRIVACY and SECURITY DMS-652-A 10/08 5.0 The Medicare Plan agrees that Arkansas Medicaid recipient information is confidential and is not to be released to the general public 5.1 The Medicare Plan agrees not to release the information governed by these Arkansas Medicaid recipient requirements to any other state agency or public citizen without the approval of the Division of Medical Services 5.2 The use or disclosure of information concerning recipients shall be limited to purposes directly connected with the administration of the state’s Arkansas Medicaid program and eligibility verification relating to Medicare Advantage and/or Medicare Part D plans 5.3 This restriction shall also apply to the disclosure of information in summary, statistical, or other form which does not identify particular individuals 5.4 Medicare Plan agrees that Arkansas Medicaid recipient and provider information cannot be re-marketed, summarized, distributed, or sold to any other organization without the express written approval of the Division of Medical Services 5.2 Medicare Plan agrees to comply with the Federal Privacy Regulations and the Federal Security Regulations as contained in 45 C.F.R Parts 160 through 164 that are applicable to such party as mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and 42 U.S.C §§ 1320d -1320d-8 5.3 Medicare Plan must report any known breach of confidentiality, privacy, or security, as defined under HIPAA, to the Division of Medical Services Privacy and Confidentiality Officer within 48 hours of knowledge of an unauthorized act Failure to perform may constitute immediate termination of contract ARTICLE VI LAWS APPLICABLE 6.0 The parties agree to abide by all federal and state statutes applicable to this Agreement 6.1 The explicit inclusion of some statutory and regulatory duties in this Agreement shall not exclude other statutory or regulatory duties 6.2 All questions pertaining to validity, interpretation and administration of this Agreement shall be determined in accordance with the laws of the State of Arkansas, regardless of where any service is performed 6.3 If any portion of this Agreement is found to be in violation of federal or state statutes, that portion shall be stricken from this Agreement and the remainder of the Agreement shall remain in full force and effect ARTICLE VII TERMINATION 7.0 This Agreement may be terminated by either party for cause with a thirty (30) day written notice to the other party Either party may terminate without cause with a sixty (60) day written notice to the other party All notices of termination must be in writing 7.1 In the event funding of the Arkansas Medicaid program from the state, federal or other sources is withdrawn, reduced, or limited in any way after the effective date of DMS-652-A 10/08 this Agreement and prior to the anticipated Agreement expiration date, this Agreement may be terminated immediately by the Division of Medical Services 7.2 Violation of the confidentiality provisions of this Agreement, as outlined in Article V, shall be grounds for immediate termination EXECUTED BY: Name and Title (printed) of Medicare Plan Authorized Designee Signature DMS-652-A 10/08 Date ... Provider, and Arkansas Division of Medical Services The provider, in consideration of the material benefits to be derived, and the covenants and undertakings of Arkansas Division of Medical Services. .. Arkansas Medicaid Program b) Division of Medical Services has authority to enter into this Agreement c) Division of Medical Services states that its mailing address for purposes of this Agreement... 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