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  • Ar-200 Direct Billing Request Form

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DIRECT BILLING REQUEST Company, Organization, Individual Responsible for Payment (Applicant): Name: Contact: Address: City: State: Zip: Type of Business: Phone: Fax: Billing Address (if different.

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How to fill out the Ar-200 Direct Billing Request Form online

Filling out the Ar-200 Direct Billing Request Form online is a straightforward process that allows applicants to request direct billing for hotel stays. This guide will help you navigate each section of the form to ensure accurate and complete submission.

Follow the steps to complete the form online effectively.

  1. Press the ‘Get Form’ button to obtain the form and access it in your online editor.
  2. Begin with entering the name of the company, organization, or individual responsible for the payment in the designated field labeled ‘Applicant.’ Make sure to include the contact information such as phone number and email.
  3. Fill in the address fields including street address, city, state, and zip code. This information is critical for correspondence related to the billing request.
  4. Indicate the type of business you are representing in the provided field. Ensure that the phone and fax numbers are correctly included.
  5. If the billing address is different from the applicant's address, complete the additional billing address section with the same detailed information.
  6. List the attention line if there is a specific contact at the organization who should receive the billing correspondence.
  7. Fill in the hotel credit references by providing the name, address, and telephone number of the hotels, along with the date of the last stay.
  8. Complete the bank reference section with the bank's name, phone number, branch location, account number, and the contact person at the bank.
  9. Designate individuals who are authorized to approve direct billing and make reservations by providing their names in the specified fields.
  10. Select the charges permitted to be billed to your company by checking the appropriate boxes.
  11. If applicable, attach a copy of the State Tax Exempt Certificate and provide your sales tax exemption number.
  12. Review the terms and conditions thoroughly, ensuring you understand your obligations related to billing and payments.
  13. Finally, sign and date the form in the designated signature area, including your title to confirm authorization.
  14. Save your changes, and then download, print, or share the completed form as required.

Complete your Ar-200 Direct Billing Request Form online today to ensure a smooth billing process!

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Typically, a Medicaid application takes 3 to 6 months to process, unless a disability determination needs to be made. The process time can also increase if the required documentation is not provided promptly. The Department of Human Services is responsible for administering the Medicaid program in Arkansas.

If you realize that a claim contained an error, the error is corrected with an edit, void, or adjustment. Electronic adjustments completed on the Health Care Provider Portal are preferred. Recorded webinars for correctly submitting both institutional claims and professional claims are available to assist you.

Questions regarding Medicaid coverage, renewals and benefits can be directed to 855-372-1084. Those with ARKids First questions should call 888-474-8275. Medicaid claims inquiries should be directed to 800-482-5431.

Section 302.000 of the AR Medicaid manual defines timely claims. There are no exceptions to the 12-month filing deadline policy. The definitions and additional federal regulations in Section 3 will permit flexibility for those who adhere closely to them.

Apply for Medicaid in Arkansas Eligibility: Children from 0-18 with incomes up to 211% of FPL; pregnant women with incomes up to 209% of FPL; parents with incomes up to 138% of FPL; non-elderly adults with household incomes up to 138% of FPL; certain elderly and disabled individuals.

If you submit paper claims, you must use your Arkansas Medicaid Provider ID. Paper claims submitted with only an NPI will be returned for correction. If you submit claims on paper, use the CMS-1500, CMS-1450, or dental claim form.

Include a letter of Medical Necessity with supporting documentation (chart notes, lab results) to assist in the PA process and fax to Magellan Arkansas Medicaid Pharmacy Unit: 800-424-7976.

Section 302.000 of the AR Medicaid manual defines timely claims. There are no exceptions to the 12-month filing deadline policy. The definitions and additional federal regulations in Section 3 will permit flexibility for those who adhere closely to them.

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