AFMC conducts retrospective emergency room reviews based on a random selection of claims billed as emergent.
A registered nurse clinical services specialist initially screens the retrospective service. If the documentation submitted supports medical necessity, the clinical services specialist may approve the service.
If the clinical services specialist is unable to approve medical necessity of the 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 service.
A random monthly selection is made from claims paid the previous month, regardless of the date of service (DOS), for each hospital in Arkansas and bordering hospitals.
- Hospital receives the following from AFMC:
- ER Cover Sheets
- Copy of hospital “pull list” (retain a copy for your records)
- Hospital provides copy of complete ER record to AFMC:
- UB-04 if available
- Nursing assessment/triage sheet
- Treatment record
- Physician’s H & P examination of patient in the emergency room
- Lab and/or imaging study results
- Records may be submitted via ReviewPoint®, USPS or carrier service.
- Providers are encouraged to utilize the preferred method of submitting electronic requests through a web-based portal called ReviewPoint®. If you are not currently enrolled to submit electronic requests, please visit AFMC’s ReviewPoint® website or reach out to your provider representative for assistance.
Benefits of utilizing the ReviewPoint® 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.
- If being mailed or sent via carrier service, the record request cover sheet must be stapled on top of each individual record (if sent to AFMC via USPS).
- Do not stamp or write on bottom of cover sheet.
- Original cover sheet and complete record must be returned for review to be performed.
- Records received without cover sheet may be returned unreviewed.
- A denial will be issued if the record is not received at AFMC within the required time frame due to a lack of documentation to support the medical necessity of the emergency room service.
- Second request for missing documentation will not be made
- If using FedEx, include AFMC’s physical address.
- Multiple record requests should be batched together and mailed in one envelope if sent to AFMC via USPS or carrier service.
- If records are not received at AFMC within 15 calendar days of the date of the request, a second request will be mailed to the hospital.
- If records are not received at AFMC within 30 calendar days of the date of the first/original request, a denial will be issued for lack of documentation to support medical necessity of the emergency service.
Note: The information on the top right-hand corner of the record request cover sheet is the information that was billed by the facility. Gainwell paid the claim based on the information billed by the facility. If a facility receives a record request cover sheet with information that was billed/paid incorrectly, the facility must return the record request cover sheet with an explanation of the billing error to AFMC. The facility should not send a record to AFMC that was not requested per the record request cover sheet.
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.
- Request must be in writing. Reconsiderations can be submitted utilizing the same methods as the initial request; however, the preferred method is electronically through ReviewPoint®.
- Submit further documentation to support medical necessity.
- Must include new information not previously submitted.
- Copy of denial letter must be attached.
- Request must be received at AFMC within 35 calendar days of the date of denial letter.
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 Arkansas Department of Health, Medicaid Provider Appeals Office, 4815 West Markham Street – Slot 31, Little Rock, AR 72205.