Pr Provider Enrollment nt
Agen enda § Top reasons for returning application to provider § Recent changes and updates § Resources available
Wh What i is R s RTP? § When an application cannot be processed due to errors or deficiencies, the application will be Returned To Provider (RTP). § If your application is RTP, you must correct the errors or deficiencies and return the completed application to Provider Enrollment. § If your application was submitted on paper, the entire application will be mailed back to you and you MUST return the complete application for processing. § If your application was submitted on the portal, you can log back into the portal, correct any issues, upload any needed attachments and re-submit online.
Common R Rea easo sons f s for R r RTP 1. W-9 2. Section IV affiliation/EFT 3. DMS-675 (Ownership Disclosure Form) 4. DMS-689 (Significant Business Transactions Disclosure Form) 5. Medicare enrollment required
W-9
Sec ec$o $on IV A IV Affi ffilia$o $on F Form rm/EFT § To enroll with Arkansas Medicaid, providers must be enrolled for electronic payments. § Two options to achieve electronic payments: 1. Section IV Affiliation Form – Individuals may affiliate with an active MD group that has EFT on file 2. EFT Form and Voided Check/Bank Letter – If not affiliating to an active MD group, all providers MUST complete the EFT form and attach a voided check or bank letter
Sec ection IV A IV Affiliation F Form rm
EFT F Form rm a and V Voided ed C Chec eck/Bank L Letter er
Bank L Letter er § Must be on bank le-erhead § Must include: • Bank authoriza6on for individual provider deposi6ng rights into bank account listed on le-er • Name of bank account owner • Rou6ng number • Account number • Bank personnel signature
DMS DMS-675 675 DMS-675 and DMS-689 are part of the online application. These sections of the application must be completed, or the application will be RTP. If compleCng the applicaCon online, there is no need to complete the paper documents or aEach them to your applicaCon.
DMS DMS-689 689
Med Medicare E e Enrollmen ent § Provider must be enrolled in Medicare, except adolescent and pediatric specialties. § Medicare enrollment must be the same state as the application’s place-of-service address.
Rec ecen ent C Changes a es and U Updates es § Processing +me: 30 days § Paper applica+ons no longer mailed back § Important dates available on the portal § Pre-populated revalida+on applica+on on the portal
Port rtal U Updates es
Reso esources A es Available h"ps://medicaid.mmis.arkansas.gov/Provider/Enroll/Enroll.aspx
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