The Arkansas Medicaid EFT authorization form sets up direct deposit of your Medicaid claim payments by linking your Medicaid Provider ID to a specific bank account. Every enrolling facility and individual provider must submit a completed form as part of enrollment, and Provider Enrollment will not accept an application without one.1Arkansas Department of Human Services. Arkansas Medicaid Authorization for Electronic Funds Transfer The same form is used later to change your banking information or cancel direct deposit.
Where to Get the Form
The form is hosted on the Arkansas Department of Human Services website in both PDF and Word formats.1Arkansas Department of Human Services. Arkansas Medicaid Authorization for Electronic Funds Transfer Enrollment materials are also available through the Arkansas Medicaid provider portal at portal.mmis.arkansas.gov.2Arkansas Medicaid. Provider Enrollment
What to Have Ready Before You Start
Every field has to be accurate the first time. Mismatched data between the form and your Medicaid enrollment records is one of the most common reasons packets get returned. Gather:
- Your provider name exactly as it appears on your Arkansas Medicaid enrollment and your IRS records.
- Your Medicaid Provider Number. Each number needs its own EFT form, so if you hold multiple enrollments, you will fill out a separate form for each one.3Arkansas Department of Human Services. Arkansas Medicaid Authorization for Electronic Funds Transfer
- Your ten-digit National Provider Identifier (NPI).
- Your federal Tax Identification Number or Social Security Number, matching your IRS records.
- The official name of your bank.
- The nine-digit ABA routing transit number.
- The full bank account number.
Filling Out the Form
The form is a single page split into provider information, financial institution information, authorization type, and signature.
Provider Information
Enter your provider name, Medicaid Provider Number, NPI, and TIN or SSN at the top of the form. Confirm the name matches your IRS documents and your Medicaid enrollment exactly. Small discrepancies like abbreviations or a missing middle initial can trigger a rejection.
Financial Institution Information
Fill in your bank’s name, the ABA routing transit number, and your account number. These must match the numbers on the voided check or bank letter you attach.3Arkansas Department of Human Services. Arkansas Medicaid Authorization for Electronic Funds Transfer
Type of Authorization
Select New, Change, or Cancel. New providers enrolling for the first time choose New. Choose Change if you are switching banks or updating account details on an existing enrollment, and Cancel to end direct deposit.
Signature
An authorized representative must sign and date the form. The signature line confirms you are responsible for the validity of the information and that you authorize the Arkansas Medicaid Program to initiate credit entries to the account listed.3Arkansas Department of Human Services. Arkansas Medicaid Authorization for Electronic Funds Transfer An original signature is required. Stamped or photocopied signatures will not be accepted.
Proof of the Bank Account
You must attach one of two documents to verify the account:
- A voided check with the account holder’s name and address pre-printed by the bank, showing the matching routing and account numbers. Temporary checks are not accepted if they lack the provider’s name and address printed by the bank.3Arkansas Department of Human Services. Arkansas Medicaid Authorization for Electronic Funds Transfer
- A bank letter on official letterhead that includes the account holder’s name, the ABA routing number, the account number, and the signature of an authorized bank employee. The account holder name must match the provider name on the form, or the letter must state that the provider has depositing rights into that account.1Arkansas Department of Human Services. Arkansas Medicaid Authorization for Electronic Funds Transfer
Name matching is where many submissions trip up. If your practice does business under one name but your bank account is under a slightly different legal name, resolve that with your bank before you submit. Any mismatch between the form and the check or letter will send the packet back.
Submitting the Form
Arkansas Medicaid accepts the completed form and attachments through two channels, and the provider portal is the preferred method.1Arkansas Department of Human Services. Arkansas Medicaid Authorization for Electronic Funds Transfer If you have portal access at portal.mmis.arkansas.gov, upload the signed form and supporting documentation there.
You can also mail the signed form and attachments to:
Medicaid Provider Enrollment Unit
Gainwell Technologies
P.O. Box 8105
Little Rock, AR 72203-81051Arkansas Department of Human Services. Arkansas Medicaid Authorization for Electronic Funds Transfer
Portal submissions tend to process faster because the documents do not sit in a mail queue. If you mail the form, keep a copy of everything you send.
What Happens After You Submit
A provider enrollment analyst reviews the form and attachments for completeness and accuracy. For new enrollments, the EFT authorization is processed as part of your overall enrollment application. Anything incomplete, or any name mismatch on the voided check or letter, will come back for correction.
Once the form clears review, the state typically runs a pre-notification before activating direct deposit. A prenote is a zero-dollar ACH transaction sent to your bank to confirm the routing and account numbers work. You will not see a deposit amount, but watch your bank records for that small entry as confirmation that the link is functional. During this window, your payments continue through whatever method was previously in place. After the prenote clears, future Medicaid reimbursements will deposit into the authorized account.
Changing or Canceling Direct Deposit Later
To update your bank account or stop direct deposit, use the same form and select Change or Cancel. Attach a new voided check or bank letter for the updated account if you are switching banks.
Banking changes get extra scrutiny. Before processing any EFT change on an existing enrollment, a provider enrollment analyst will call you at the phone number on file for your Medicaid ID to confirm you actually requested the change.1Arkansas Department of Human Services. Arkansas Medicaid Authorization for Electronic Funds Transfer This callback does not apply to brand-new enrollments. If the analyst cannot reach you, the change will not go through, so make sure the phone number on your Medicaid enrollment is current before you submit an update.
When a Separate Form May Not Be Needed
If you bill under a group billing Medicaid ID as a rendering provider, claim payments go to the billing provider’s Medicaid ID and the bank account registered to that group, not to your individual account.1Arkansas Department of Human Services. Arkansas Medicaid Authorization for Electronic Funds Transfer Individual providers eligible for Section IV group linkage may not need to submit their own separate EFT form as part of enrollment. Section IV linkage applies to specific provider types, including individual providers linked to MD groups and certain behavioral health or autism treatment groups.4AFMC. Provider Enrollment If you are unsure whether your provider type qualifies, check with Provider Enrollment before submitting. A missing Section IV form is one of the top reasons enrollment applications get returned.
Who to Call With Questions
For questions about the EFT form, your enrollment status, or a banking change, contact the Arkansas Medicaid Provider Enrollment unit at (800) 457-4454 or (501) 376-2211, Monday through Friday, 8:00 a.m. to 5:00 p.m. Central time.5Arkansas Medicaid. Contact Us