Lab, radiology, physician and outpatient visits
Effective Feb. 1, 2005, AFMC began review for Arkansas Medicaid EOB requests for clinical, outpatient, laboratory and radiology services. Requests are considered only after the service(s) have been rendered and a claim is filed and subsequently denied because the patient’s benefit limits have been exhausted. Medicaid has a benefit limit per state fiscal year of:
- Diagnostic laboratory services benefits are limited to five hundred dollars ($500) per State Fiscal Year (SFY: July 1 through June 30), and radiology/other services benefits are limited to five hundred dollars ($500) per SFY. See Section 229.100 in the Arkansas Medicaid Physician’s Provider Manual.
- Physician services in a physician’s office, patient’s home or nursing home for beneficiaries aged twenty-one (21) or older are limited to twelve (12) visits per state fiscal year (July 1 through June 30). See Section 226.000 in the Arkansas Medicaid Physician’s Provider Manual.
- Medicaid-eligible beneficiaries age twenty-one (21) and older are limited to a total of twelve (12) outpatient hospital visits a year. This benefit limit includes outpatient hospital services provided in an acute care, general, or a rehabilitative hospital. This yearly limit is based on the State Fiscal Year (July 1 through June 30). See Section 225.000 in the Arkansas Medicaid Physician’s Provider Manual.
- Providers have the option of filing the EOB request on behalf of their recipients. See Section 220.000, Benefit Limit
Pathology and radiology referral forms
Pathology referral form – use this form when referring a patient for lab tests
Radiology referral form – use this form when referring a patient for radiology testing
Current EOB review process
229.100 Extension of Benefits for Laboratory and X-Ray, Physician Office, and Outpatient Hospital Services 7-1-22
A registered nurse Clinical Services Specialist initially screens the EOB request. If the documentation submitted supports medical necessity, the Clinical Services Specialist may approve the requested service.
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.
- Requests for extension of benefits for diagnostic laboratory, radiology/other, physician office and outpatient services must be submitted to AFMC.
- Requests may be submitted via Arkansas Medicaid Healthcare Provider Portal, mail, carrier service or fax.
- 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:
- 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 submitted via mail or carrier service please use Arkansas Foundation for Medical Care (AFMC), Attn: EOB Clinical Services, 5111 Rogers Ave. Suite 476, Fort Smith, AR 72903 or P.O. Box 180001, Fort Smith, AR 72918-0001
- Requests for extension of benefits are considered only after a claim is filed and is denied because the patient’s benefit limits are exhausted.
- Submit with the request a copy of the Medical Assistance Remittance and Status Report reflecting the claim’s denial for exhausted benefits. Do not send a claim.
- A request for extension of benefits must be received by AFMC within 90 calendar days of the date of benefits-exhausted denial.
- Additional information will be requested as needed to process a benefit extension request. Reconsiderations of additionally requested information are not available. Failure to provide requested information within the specified time will result in a technical denial.
229.110 Completion of Request Form DMS-671, “Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services” 7-1-22
- Requests for extension of benefits for clinical services (physician’s visits), outpatient services (hospital outpatient visits), diagnostic laboratory services (laboratory tests) and radiology/other services must be submitted to AFMC.
- Consideration of requests for extension of benefits requires correct completion of all fields on the “Request for Extension of Benefits for Clinical, Outpatient, Diagnostic Laboratory, and Radiology/Other Services” form (Form DMS-671). View or print Form DMS-671.
- Instructions for accurate completion of Form DMS-671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each Provider Manual.
229.120 Documentation Requirements 7-1-22
- To request extension of benefits for any benefit limited service, all applicable records that support the medical necessity of extended benefits are required.
- Documentation requirements are as follows.
- Clinical records must:
- Be legible and include records supporting the specific request;
- Be signed by the performing provider;
- Include clinical, outpatient, or emergency room records (as applicable) for dates of service in chronological order;
- Include related diabetic and blood pressure flow sheets;
- Include a current medication list for the date of service;
- Include the obstetrical record related to a current pregnancy (when applicable); and
- Include clinical indication for diagnostic laboratory and radiology/other services ordered with a copy of orders for diagnostic laboratory and radiology/other services signed by the physician.
- Diagnostic laboratory and radiology/other reports must include:
- Clinical indication for diagnostic laboratory and radiology/other services ordered;
- Signed orders for diagnostic laboratory and radiology/other services;
- Results signed by the performing provider; and
- Current and all previous ultrasound reports, including biophysical profiles and fetal non-stress tests (when applicable).
- Clinical records must:
229.130 Administrative Reconsideration of Extensions of Benefits Denial 8-1-21
- A request for administrative reconsideration of an extension of benefits denial must be in writing and submitted to DHS or its designated vendor within thirty (30) calendar days of the denial. The request must include a copy of the denial letter and additional supporting documentation pursuant to Section 229.120.
- The deadline for receipt of the reconsideration request will be enforced pursuant to Sections 190.012 and 190.013 of the Arkansas Medicaid Provider Manual. A request received within thirty-five (35) calendar days of a denial will be deemed timely. A request received later than thirty-five (35) calendar days gives rise to a rebuttable presumption that it is not timely.
229.140 Appealing an Adverse Action 2-1-06
Please see Section 190.000 et al. in the Arkansas Medicaid Provider Manual for information regarding administrative appeals.
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.