Form AAS-9582 "Targeted Case Management Provider Application" - Arkansas

What Is Form AAS-9582?

This is a legal form that was released by the Arkansas Department of Human Services - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2018;
  • The latest edition provided by the Arkansas Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AAS-9582 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Human Services.

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Download Form AAS-9582 "Targeted Case Management Provider Application" - Arkansas

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Navigating the Provider Certification Process
If you are applying as a NEW provider, complete Parts A and B.
If you applying for a RENEWAL, complete Part A only.
Part A
New and Renewal Applicants
Find the new/renewal application:
https://humanservices.arkansas.gov/about-dhs/dpsqa/agency-provider-certification
 Complete each application and submit the following with each application:
o A copy of liability insurance or bond.
o A current list of criminal background check for each employee and supervisor.
o A copy of the in-service training schedule for the current year.
o If required, a copy of your agency’s license issued by the Arkansas Department of
Health (1-800-462-0599).
 Send all requested documents by email, fax, or standard US postal mail to the following:
DPSQA.ProviderApplications@dhs.arkansas.gov
o Email Address:
501-682-6245
o Fax Number:
o Mailing Address: DHS/DPSQA
ATTN: Certification Unit
PO BOX 1437-Slot S530
Little Rock, AR 72203-1437
Part B
New Applicants ONLY
 Once you receive a letter from the DPSQA Certification Unit with your certificate number,
you must download the letter during the Medicaid application process at:
https://portal.mmis.arkansas.gov/armedicaid/provider/Home/ProviderEnrollment/tabid/477/Default.aspx
 After your Medicaid application and fees have been submitted, Medicaid will issue a PIN
(Provider Identification Number). This PIN allows you to bill for Medicaid Services and be
paid. Please allow 30-60 days for processing.
 The DPSQA Certification Unit will mail you a certificate with your PIN and expiration
date when all steps have been completed!
Navigating the Provider Certification Process
If you are applying as a NEW provider, complete Parts A and B.
If you applying for a RENEWAL, complete Part A only.
Part A
New and Renewal Applicants
Find the new/renewal application:
https://humanservices.arkansas.gov/about-dhs/dpsqa/agency-provider-certification
 Complete each application and submit the following with each application:
o A copy of liability insurance or bond.
o A current list of criminal background check for each employee and supervisor.
o A copy of the in-service training schedule for the current year.
o If required, a copy of your agency’s license issued by the Arkansas Department of
Health (1-800-462-0599).
 Send all requested documents by email, fax, or standard US postal mail to the following:
DPSQA.ProviderApplications@dhs.arkansas.gov
o Email Address:
501-682-6245
o Fax Number:
o Mailing Address: DHS/DPSQA
ATTN: Certification Unit
PO BOX 1437-Slot S530
Little Rock, AR 72203-1437
Part B
New Applicants ONLY
 Once you receive a letter from the DPSQA Certification Unit with your certificate number,
you must download the letter during the Medicaid application process at:
https://portal.mmis.arkansas.gov/armedicaid/provider/Home/ProviderEnrollment/tabid/477/Default.aspx
 After your Medicaid application and fees have been submitted, Medicaid will issue a PIN
(Provider Identification Number). This PIN allows you to bill for Medicaid Services and be
paid. Please allow 30-60 days for processing.
 The DPSQA Certification Unit will mail you a certificate with your PIN and expiration
date when all steps have been completed!
Targeted Case Management Provider Application
STATE OFFICE USE ONLY
Reviewed by: ____________________________________________
Date: _______________
DOCUMENTS:
_____ INS
____ LIC
_____ IN-SER
_____BKGR
NOTES:
Date Completed _____________________________
NEW Application
OR RENEWAL Application
Please Attach Only ONE Copy of Each Requested Document
Provider Name
______________________________________________________
SECTION ONE—Provider Information (Please type or print)
Corporate Name
EIN
DBA Name
Street Address and/or PO Box
City
State
Zip Code
)
(
Contact Person
Title
Telephone Number
E-Mail Address
Website
Mailing address if different from above:
Street Address and/or PO Box
City
State
Zip Code
DPSQA.ProviderApplications@dhs.arkansas.gov
Email Address:
501.682.6245
Fax Number:
DHS/DPSQA
Mailing Address:
ATTN: Certification Unit
PO BOX 1437-Slot S-530 Little Rock, AR
72203-1437
AAS-9582 ARChoices TCM Provider Application rev 9/18 Page 1 of 2
SECTION TWO—Application Attachments/Experiences
Please check below, which applies:
____ Licensed as a Class A Home Health Agency by the Arkansas Department of Health (attach a copy of your
agency’s Class A Home Health Agency license that your agency will be operating under for the period
____________________.) Since you will not receive this license from the Department of Health until sometime in
January, please send a copy as soon as it is received.
____ Licensed as a Class B Home Health Agency by the Arkansas Department of Health (attach a copy of your
agency’s Class B Home Health Agency license that your agency will be operating under for the period
____________________.) Since you will not receive this license from the Department of Health until sometime in
January, please send a copy as soon as it is received.
____ A Unit of State Government (specify) _________________________________________
(Attach some form of documentation for the period _____________documenting that
your agency is a “Unit of State Government”)
____ Other Agency (specify) ______________________________________________________
(Attach a copy of one of the following for the period _____________________:
Your agency’s Private Care Agency - Medicaid Personal Care license through the Arkansas Department
of Health; or
Your agency’s Adult Day Services license or Adult Day Health Services license through the Division of
Medical Services, Office or Long Term Care; or
Your agency’s services provider certificate issued through the Division of Aging & Adult Services; or
Your agency’s Articles of Incorporation from the Arkansas Secretary of State’s Office; or
Some other form of documentation that your agency is an “Agency.”
If you checked “other agency,” please supply the following answers:
1. This agency has performed case management services from ____________ to ____________. Please indicate to
whom the agency has performed case management services.
2. This agency has worked specifically in the field of aging from _____________ to ____________.
ATTACH the following requested documents to this application:
A spreadsheet of a current list of a criminal background check for each employee and supervisor.
Have you lived continuously in
Have you lived in another state within
Date of Last
FULL NAME
Arkansas for the last 5 years?
the past 5 years? If so, what state?
Background Check
John Lewis Doe
No
List State(s)
01/15/2014
Sarah Jane Doe
Yes
Arkansas
06/08/2012
A copy of liability insurance or bond.
A copy of in-service training schedule for each employee and supervisor for the past year.
If required, a copy of your agency’s license issued by the Arkansas Department of Health
(1-800-462-0599).
AAS-9582 ARChoices TCM Provider Application rev 9/18
Page 2 of 2
SECTION THREE—Provider Assurances Verification
A.
Agency Staffing
The Provider agrees that he or she will maintain adequate staffing levels to ensure timely and consistent delivery
of services to all beneficiaries for whom they have accepted an ARChoices Waiver Person-Centered Service Plan
(PCSP).
The Provider agrees:
1.
Personnel responsible for direct service delivery will be properly trained and in compliance with all
applicable licensure requirements. The Provider agrees to require personnel to participate in any
appropriate training provided by, or requested by, the Department of Human Services.
The Department
of Human Services requires mandatory training. The Provider must attend one of the two provider
workshop trainings in the calendar year. Failure to attend one of these trainings could jeopardize the
provider’s certification for the waiver.
The Provider acknowledges the cost of training courses for
certification and/or licensure is not reimbursable through DHS. Direct care workers must be trained prior
to providing services to an ARChoices beneficiary.
2.
Each service worker possesses the necessary skills to perform the specific services required to meet the
needs of the beneficiary he/she is to serve.
3.
Staff is required to attend orientation training prior to allowing the employee to deliver any ARChoices
Waiver service(s). This orientation shall include, but not be limited to:
a.
Description of the purpose and philosophy of the ARChoices Waiver Program;
b.
Discussion and distribution of the provider agency’s written code of ethics;
c.
Discussion of activities which shall and shall not be performed by the employee;
d.
Discussion, including instructions, regarding ARChoices Waiver record keeping requirements;
e.
Discussion of the importance of the PCSP;
f.
Discussion of the agency’s procedure for reporting changes in the beneficiary’s condition;
g.
Discussion, including potential legal ramifications, of the beneficiary’s right to confidentiality;
h.
Discussion of the beneficiary's rights regarding HCBS Settings as discussed in 201.000.
B.
Code of Ethics
The Provider agrees to follow and/or enforce for each employee providing services to an ARChoices Waiver
beneficiary a written code of ethics that shall include, but not be limited to, the following:
1.
No consumption of the beneficiary’s food or drink;
2.
No use of the beneficiary’s telephone for personal calls;
3.
No discussion of one’s personal problems, religious or political beliefs with the beneficiary;
4.
No acceptance of gifts or tips from the beneficiary or their caregiver;
5.
No friends or relatives of the employee or unauthorized beneficiaries are to accompany the employee to
beneficiary’s residence;
6.
No consumption of alcoholic beverages or use of non-prescribed drugs prior to or during service delivery;
7.
No smoking in the beneficiary’s residence;
8.
No solicitation of money or goods from the beneficiary;
9.
No breach of the beneficiary’s privacy or confidentiality of records.
C.
Home and Community-Based Services (HCBS) Settings
All providers must meet the following Home and Community-Based Services (HCBS) Settings regulations as
established by CMS. The federal regulation for the new rule is 42 CFR 441.301(c) (4)-(5).
AAS-9558 ARChoices Provider Assurances rev. 9/18 Page 1 of 3
Settings that are HCBS must be integrated in and support full access of beneficiaries receiving Medicaid HCBS to the
greater community, including opportunities to seek employment and work in competitive integrated settings, engage
in community life, control personal resources and receive services in the community, to the same degree of access as
beneficiaries not receiving Medicaid HCBS.
HCBS settings must have the following characteristics:
1.
Chosen by the individual from among setting options including non-disability specific settings (as well as
an independent setting) and an option for a private unit in a residential setting.
a.
Choice must be identified/included in the person-centered service plan.
b.
Choice must be based on the individual’s needs, preferences and, for residential settings, resources
available for room and board.
2.
Ensures an individual’s rights of privacy, dignity and respect and freedom from coercion and restraint.
3.
Optimizes, but does not regiment, individual initiative, autonomy and independence in making life
choices, including but not limited to, daily activities, physical environment and with whom to interact.
4.
Facilitates individual choice regarding services and supports and who provides them.
5.
The setting is integrated in and supports full access of beneficiaries receiving Medicaid HCBS to the
greater community, including opportunities to seek employment and work in competitive integrated
settings, engage in community life, control personal resources and receive services in the community, to
the same degree of access as beneficiaries not receiving Medicaid HCBS.
6.
In a provider-owned or controlled residential setting (e.g., Adult Family Homes), in addition to the
qualities specified above, the following additional conditions must be met:
a.
The unit or dwelling is a specific physical place that can be owned, rented, or occupied under a
legally enforceable agreement by the individual receiving services, and the individual has, at a
minimum, the same responsibilities and protections from eviction that tenants have under the
landlord/tenant law of the State, county, city, or other designated entity. For settings in which
landlord tenant laws do not apply, the State must ensure that a lease, residency agreement or other
form of written agreement will be in place for each HCBS participant and that the document
provides protections that address eviction processes and appeals comparable to those provided
under the jurisdiction's landlord tenant law.
b.
Each individual has privacy in their sleeping or living unit:
i.
Units have entrance doors lockable by the individual, with only appropriate staff having keys
to doors.
ii.
Beneficiaries sharing units have a choice of roommates in that setting.
iii.
Beneficiaries have the freedom to furnish and decorate their sleeping or living units within
the lease or other agreement.
c.
Beneficiaries have the freedom and support to control their own schedules and activities and have
access to food at any time.
d.
Beneficiaries are able to have visitors of their choosing at any time.
e.
The setting is physically accessible to the individual.
f.
Any modification of the additional conditions specified in items 1 through 4 above must be
supported by a specific assessed need and justified in the person-centered service plan. The
following requirements must be documented in the person-centered service plan:
i.
Identify a specific and individualized assessed need.
ii.
Document the positive interventions and supports used prior to any modifications to the
person-centered service plan.
iii.
Document less intrusive methods of meeting the need that have been tried but did not work.
iv.
Include a clear description of the condition that is directly proportionate to the specific
assessed need.
AAS-9558 ARChoices Provider Assurances rev. 9/18 Page 2 of 3