Application Information

• Instructions for how to complete your application
• Video instruction for how to complete your application
• Required Documents Finder
• Start your application

Top 4 Provider Enrollment Issues When Applying on the Portal

Arkansas Medicaid provider enrollment applicants should gather all needed materials before applying to streamline the process. Below are the four most common reasons why applications are denied.

• Name Mismatch
  The name on every document, including on all attachments, must match. In other words, the name on the application must match the licenses or certifications, W-9, and any other document submitted. For example, if a provider applies as “Benjamin J. Smith” and provides a license that says “James Smith,” the application cannot be accepted because of mismatching names.
• Incorrect W-9
  For a provider enrolling as an individual, the W-9 must be completed with the individual’s information (name and Social Security Number). For a group, the W-9 must be completed with the group’s information (name and Tax ID).
• Missing Attachments
  If a provider does not submit all the required attachments for the provider type, the system will not allow the application to be submitted. Providers can use the Required Documents Finder (Excel, new window) to find out which documents are required for each provider type.
  • Provider types applying as an individual should be prepared to submit:
    • License or certification
    • Electronic Funds Transfer Authorization form with voided check/bank letter
    • W-9
  • Provider types applying with or as a group should be prepared to submit:
    • IRS letter such as an SS4, 147C, or 501C3
    • Section IV – Group affiliation form
    • Ownership Disclosure Form – a full list of board members, if applicable
• Incorrect Signature
  Applications are denied when they do not have the correct signature to agree to the terms of enrollment.
  • For an individual provider, the application must be signed by that individual provider.
  • If the application is for a group, the application must be signed by an authorized signer such as a managing employee who should be listed on the Ownership Disclosure form.
    NOTE: This information is submitted as part of the application on the portal, but if the application is submitted by paper, the Ownership Disclosure Form must be completed.

If you have any questions about your application, call the Arkansas Medicaid Provider Enrollment Office at
(501) 376-2211 or view FAQs below and job aids.

FAQ

How can I become an Arkansas Medicaid provider?

To enroll as an Arkansas Medicaid provider, go the the online enrollment application. When applying online, there is less possibility for making errors that would result in your application being denied and returned to you for correction. If you fail to enter needed information, you will be prompted to provide the missing information.

If you have questions about how to enroll, call Arkansas Medicaid Provider Enrollment at (501) 376-2211 or toll free at (800) 457-4454. When prompted, select 0 for “Other Inquiries”, then option 3 for “Provider Enrollment”. View or print Provider Enrollment contact information.

If you are required to have a National Provider Identifier (NPI), you must report it to Arkansas Medicaid once enrolled as an Arkansas Medicaid provider. For more information about the NPI, view NPI frequently asked questions.

Who must pay an application fee?

Certain provider types are subject to an application fee set by the Centers for Medicare & Medicaid Services (CMS). The fee may be adjusted from year to year and is payable every five (5) years. This federally mandated fee is used to offset the cost of conducting screening activities associated with the ACA.

View the list of providers required to pay the fee.

• If the provider is enrolled in Medicare and has paid the application fee to Medicare, or if the provider is enrolled in another state’s Medicaid Program and has paid the application fee to that state’s Medicaid Agency, the provider is not required to pay the application fee to Arkansas Medicaid.
• Individual providers (such as physicians, dentists, therapists) and groups of individual providers (such as physician groups, dental groups, and therapy groups) are not required to pay the application fee.

Who must complete a fingerprint-based background check to become an Arkansas Medicaid provider?

In accordance with title 42 CFR 455.434, 42 CFR 455.50 (c), and the Arkansas Provider manual section 141.103, federal fingerprint-based background checks are required for all high-risk providers and their owners who have a 5% or greater direct or indirect ownership interest as a condition of enrollment in the Arkansas Medicaid program.

Applicants who are required to complete the fingerprint-based background check will be notified by a letter from Provider Enrollment that will instruct how to complete the process. View or print a sample fingerprint-based background check letter.

How can I apply for a temporary Arkansas Medicaid provider number?

Arkansas Medicaid does not issue temporary provider numbers. To obtain an Arkansas Medicaid provider ID number, you must complete an application for enrollment.

How often must I re-enroll?

All providers are required to re-enroll every five (5) years regardless of provider type.

What are some tips for helping my provider application or re-enrollment progress more smoothly?

Our enrollment specialists have listed some tips to help your application or re-enrollment progress more smoothly.

• Apply online. Use the assigned tracking number to check your application’s status. You can also renew and revalidate your enrollment online using Resume Enrollment.
• You must submit credentials annually. A good rule of thumb is to Resume Enrollment on the Health Care Provider Portal when you mail your license/certification renewal fees to your state. Please make certain you attach the current license. Always check the expiration date before attaching.
• When submitting credentials for re-enrollment, always add your provider number. This will help us process your renewal more quickly if there are several providers under the same tax ID number.
• When enrolling for Electronic Fund Transfer (EFT) Authorization for Automatic Deposit, you must attach a voided check or a signed letter from the bank. Deposit slips are not accepted to set up EFTs.
• If you have been inactive with Arkansas Medicaid for 6 months, you must submit a new application.
• W-9 forms and contracts for individual providers must be submitted in their name, with their Social Security number, and their original signature. If the W-9 or contract is for a group or facility, it must include the tax ID number and an original signature.

How can I change my PCP caseload?

Providers can change their patient caseloads on the Health Care Provider Portal. If the PCP caseload is set over 2500 using the online form, an error will be reported and no change will be made. If you would like to set the PCP caseload over 2500, Provider Enrollment requires a written request stating why the higher caseload is needed. The request should be attached online.

How can I change my demographic information?

Demographic information can be viewed after you have logged onto the Health Care Provider Portal under Characteristics. You must call enrollment to update this information, however. This is a security feature for your protection.

Why can’t I access the Health Care Provider Portal?

Only currently active providers have access to the Health Care Provider Portal. Inactive or suspended providers must contact the Provider Enrollment Unit before they will be able to log on the portal.

Both providers and trading partners are required to register on the Health Care Provider Portal. It is possible that you must register as both a provider AND a Trading Partner.

HIPAA requirements mandate the following security measures for the Health Care Provider Portal:

• Users will be automatically directed to change their password if it matches their Tax ID/SSN or Medicaid/BreastCare provider ID.
• Passwords must meet all of the password requirements for the Health Care Provider Portal.
• Users must select a security question and provide an answer to that question to be used later to unlock the account or recover a password.
• Security question answers must:
  • Be at least 4 characters long
  • NOT contain the user ID
  • NOT contain the security question
• Users will be redirected to the log-on page if there is no activity on a secure page for more than 20 minutes.
• Users will be locked out of an account automatically after six failed log in attempts within an hour.

What are the requirements for passwords on the Health Care Provider Portal?

Passwords for the Health Care Provider Portal must adhere to specific requirements. All passwords are case sensitive and must:

• Be between 8 and 20 characters in length
• Contain at least 1 alpha character
• Contain at least 1 numeric character
• Contain at least 1 uppercase character
• Contain at least 1 lowercase character
• Contain at least 1 special character
• NOT contain the same character more than twice
• NOT contain the user ID
• NOT be any of the previous 6 passwords

Where can I get more information about Practitioner Identification Numbers (PIN)?

Frequently asked questions regarding Practitioner Identification Numbers (PIN) has been added to the website. View PIN frequently asked questions.

When completing my enrollment application electronically, am I required to mail original signatures?

No. Providers can now complete and sign their applications electronically on the Health Care Provider Portal – there’s no longer a need to send anything on paper.

What electronic and digital signatures will Arkansas Medicaid accept?

Arkansas Medicaid will accept electronic signatures in compliance with Arkansas Code § 25-31-103 et seq.

Printable Enrollment-Related Forms

• Address Change Form (DMS-673)
• Change of Ownership Form (DMS-0688)
• Contract to Participate in Arkansas Medicaid (DMS-653)
• Data Sharing Agreement (DMS-652A)
• Electronic Fund Transfer (EFT) Authorization for Automatic Deposit
• EPSDT Agreement (DMS-831)
• Disclosure of Significant Business Transactions (DMS-689)
• Home Health Agency (Provider Type 14) Annual Surety Bond Form
• Medicaid Primary Care Physician (PCP) Certification and Attestation Form
• NPI Change Form
• NPI Reporting Form (DMS-683)
• Office of Long Term Care Contract
• Ownership and Conviction Disclosure (DMS-675)
• PCP Agreement (DMS-2608)
• Practitioner Identification Number Request Form (DMS-7708)
• Provider Enrollment Application and Contract Packet
• Section IV – Group Affiliation
• W-9