Provider Forms and Resources

Forms

Provider Authorizations Forms

• Certification of Need
• Empower Prior Authorization Form for Behavioral Health or Developmental Disability Providers
• Empower Prior Authorization Form for Medical Services
• Outpatient Information for Residential Request
• Quick Reference Guide for ABA Requests
• Quick Reference Guide for Continued Stay Requests
• Quick Reference Guide for Continued Stay Requests – Acute

Archive

Utilization Management

• Second Opinion Request Form

Provider Network Forms

• Provider Roster Form
• Out of Network Provider Portal Access Request
• 2020 Empower PCP PIP Attestation
• 2020 Empower QIP Attestation
• Beacon Site Visit Tool
• Access Site Visit Tool

Claims Forms

• Empower Claim Inquiry Form
• Empower Voluntary Self Disclosure of Overpayment Form

Incident Reporting Forms

• Arkansas PASSE Incident Report Form

Resources

Care Coordination Resources

• Empower Welcome Letter Sample
• Addition of New Services to PCSP
• Initial/Annual Review Process for PCSP
• Change of Provider for PCSP

Prior Authorization Resources

• Quick Reference Guide for Key Contact Information and Prior Authorization
• Outpatient Behavioral Health Benefit Limits
• Outpatient Day Treatment Benefit Limits
• Outpatient Medical Benefit Limits
• Empower DME Specific Benefit Limits

Archive

Claims Resources

• Change Healthcare On Demand Ticketing System User Guide
• Change Healthcare On Demand Support
• Empower ADDT Medicare Bypass Codes
• Empower EIDT Medicare Bypass Codes
• Empower Medicare Bypass Codes
• Empower Third Party Liability Bypass Codes
• Job Aid – Modifying a Claim submitted on the Empower Portal
• Job Aid – Provider Validation Requirements CMS 1500 Electronic CHC Connect Taxonomy
• Job Aid – Provider Validation Requirements for CMS 1500 via EDI
• Job Aid – Provider Validation Requirements for CMS 1500 via Provider Portal
• Job Aid – Provider Validation Requirements for UB04 via EDI
• Job Aid – Provider Validation Requirements for CMS 1500 Paper
• Job Aid – Provider Validation Requirements for UB04 CHC Connect
• Job Aid – Provider Validation Requirements for UB04 Paper
• Provider Portal User Guide
• Tips for Completing the UB04 (CMS-1450) claim form
• Tips for Completing the CMS-1500 claim form
• Instamed ERA/EFT FAQ

PASSE Resources

• PASSE Eligibility Job Aide
• PASSE PCP Infographic
• PASSE Press Release 4-30-19
• PASSE Program Update 4-30-19
• PASSE Client Letter Sample 4-30-19
• Enrollment for DME Providers to Bill Specialty Waiver Products
• Arkansas Medicaid Has Made Improvements to Provider Enrollment Process
• Arkansas Medicaid Procedure Codes for Occupational, Physical, Speech-Language Therapy Effective September 1, 2019
• Arkansas Medicaid Occupational, Physical and Speech Therapy Service Fee Schedule

Quality Improvement Resources

• Empower 2020 Hedis Summary Table
• Empower 2020 Provider Survey Results
• Timeframes for Medical Record Documentation Audits
• Medical Record Documentation Audit – Behavioral Health Physicians Checklist
• Medical Record Documentation Audit – Primary Care Physician Checklist

Waiver Resources

• Waiver Provider Letter
• Waiver Codes for 2020
• Waiver Code Descriptions
• Frequently Asked Questions from CES Providers