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
Provider Network Forms
- Provider Roster Form
- Out of Network Provider Portal Access Request
- 2020 Empower PCP PIP Attestation
- 2020 Empower QIP Attestation
Claims Forms
Incident Reporting Forms
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
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
- Timeframes for Medical Record Documentation Audits
- Medical Record Documentation Audit – Behavioral Health Physicians Checklist
- Medical Record Documentation Audit – Primary Care Physician Checklist
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