Arkansas Medicaid requires that some surgical procedures be authorized by AFMC prior to the performance of the procedure. Procedures can require authorization regardless of whether they are performed on an inpatient or outpatient basis.
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.
For telephonic requests, call AFMC at 800-426-2234 between 8:00 a.m.-12:00 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.
See “Obtaining Prior Authorization of Restricted Medical and Surgical Procedures” in the Arkansas Medicaid Physician’s Provider Manual, Section 261.000.
CPT codes that require prior authorization by AFMC can be found in your Arkansas Medicaid Physician’s Provider Manual (Section 262.000 Procedures That Require Prior Authorization). These manuals, as well as the manual updates, are disseminated to all Arkansas Medicaid providers by Medicaid.
The following information is required for AFMC to conduct a review for the medical necessity of a prior-authorization procedure:
- Patient name and address (including zip code)
- Patient birthdate
- Patient Medicaid number
- Admission and procedure date
- Hospital or ambulatory surgery center name
- Facility Medicaid provider number
- Medicaid provider number of physician performing procedure
- CPT code for procedure(s)
- Principal diagnosis and any other diagnoses
- Signs/symptoms of illness
- Medical indication for justification of procedure(s)
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, an 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 Arkansas Department of Health, Medicaid Provider Appeals Office, 4815 West Markham Street – Slot 31, Little Rock, AR 72205.