For medical payments to be made to an assistant surgeon, the physician who wishes to use an assistant surgeon must obtain prior authorization from AFMC. Assistant surgeon services are only reimbursed when provided by a physician. See Section 251.110 of the Arkansas Medicaid Physician’s Provider Manual for assistant surgeon. For prior authorization instructions, see Section 261.000 in the Arkansas Medicaid Physician’s Provider Manual. This provision applies to all surgery. (Section 241.000 in the Arkansas Medicaid Hospital Provider Manual regarding Assistant Surgery program coverage.)
A registered nurse Clinical Services Specialist initially screens the prior authorization requests. If the documentation submitted supports medical necessity, the Clinical Services Specialist may approve the prior authorization.
If the Clinical Services Specialist is unable to approve medical necessity of the requested service, the review is referred to a physician advisor for determination. AFMC utilizes physicians who are licensed in the state of Arkansas to review the prior authorization requests. The physician advisor uses his/her medical judgment in accordance with established Medicaid policies to review medical necessity of the requested service.
Providers are encouraged to utilize the preferred method of submitting electronic requests through the web-based Arkansas Medicaid Healthcare Provider Portal. If you are not currently enrolled to submit electronic requests, please visit the link below or reach out to your provider representative for assistance.
Benefits of utilizing the Arkansas Medicaid Healthcare Provider Portal for electronic submissions are as follows:
- Reduces time and expense associated with paper submissions
- 24/7 access for providers to submit requests and review results
- Requests can be tracked from submission to completion.
- Providers can view decision results immediately upon review completion.
- Secure and HIPAA compliant
- Records can be directly attached to the request.
AFMC precertification phone number: 800-426-2234
AFMC clinical services phone hours: 8:00 a.m.-12 p.m. and 1:00 p.m.-4:30 p.m. Monday through Friday, except for holidays. All calls are monitored for quality assurance purposes.
When calling AFMC to obtain authorization for an assistant surgeon, the following information will be required:
- Patient name and address (including zip code)
- Patient birth date
- Patient Medicaid number
- Admission and procedure date
- Hospital or ambulatory surgery center name
- Facility Medicaid provider number
- Medicaid provider number and name of primary surgeon
- Office phone number of primary surgeon
- CPT code for procedure(s)
- Principal diagnosis and any other diagnoses
- Signs/symptoms of illness
- Medicaid provider number and name of assistant surgeon
- A medical explanation of why an assistant surgeon is required — for instance, the complexity of the procedure requires two surgeons to perform the procedure simultaneously
Notice of adverse actions, reconsideration, appeals and hearings
If AFMC is unable to fully approve any requested service, all applicable parties are notified in writing of the review determination along with detailed instructions on how to request an appeal.
The provider may request reconsideration of the denial within 35 calendar days of the date on the denial letter. Requests must be made in writing and include a copy of the denial letter and additional documentation to substantiate the medical necessity of the requested services. Requests received after 35 calendar days of the denial date will not be accepted for reconsideration.
If the denial decision is reversed during the reconsideration review, approval is forwarded to the provider specifying the approved units and services. If the denial decision is upheld, the provider and the Medicaid client will be notified in writing of the review determination. Reconsideration is available only once per prior authorization request.
Reconsiderations can be submitted utilizing the same methods as the initial request; however, the preferred method is electronically through the Arkansas Medicaid Healthcare Provider Portal.
Fair hearing requests
The Medicaid client may request a fair hearing of a denied review determination made by either the Utilization Review Department of Human Services (DHS) or AFMC. The fair hearing request must be in writing and sent to the Appeals and Hearings Section of DHS within 35 calendar days of the date on the denial letter.
Providers may refer to Section 190.000 of the Arkansas Medicaid Provider Manual for more information. Medicaid Provider Fair Hearing requests must be sent to the Arkansas Department of Health, Medicaid Provider Appeals Office, 4815 West Markham Street – Slot 31, Little Rock, AR 72205.