Services provided include durable medical equipment including specialized wheelchairs, wheelchair seating systems, specialized rehabilitation equipment and the augmentative communication device. Other items that may be covered include medical supplies, nutritional formulas, prosthetic devices and orthotic appliances.
AFMC performs prior authorization reviews for the following:
- Respiratory and diabetic equipment
- Some medical supplies (insulin infusion pump supplies, drug infusion catheter and pump supplies, compression burn garments)
- Enteral nutrition infusion pump and pump supply kit for individuals under age 21
- MIC-KEY skin level gastrostomy tube (Mic-Key Button) and supplies for individuals under age 21
- Durable medical equipment, including wheelchairs, wheelchair seating systems and wheelchair repairs
- Orthotic appliances
- Prosthetic devices
- Specialized rehabilitation equipment
- Augmentative communication devices
Please refer to Section II of the Medicaid Prosthetics Manual for complete program information.
Requests for prior authorization of the above items must be submitted to AFMC on the Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components Form DMS-679A.
Consideration of prior authorization requests by AFMC requires correct completion of all fields on the request form. The prior authorization request form must contain current medical documentation of the necessity of the required prosthetics. If necessary, AFMC may request additional information.
AFMC review process
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 equipment.
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.
Upon completion of each prior authorization request, AFMC provides written notification of the review determination to the requesting provider and the Medicaid beneficiary.
Approval notifications – include each procedure code/modifiers and units approved along with the authorization number for billing
Denial notifications – include case-specific clinical rationale and detailed information about how to appeal the determination, including the time frame allowed for submission and the requirement to provide additional information to support the medical necessity of the service denied
Due process rights
If AFMC is unable to fully approve any requested service, all applicable parties are notified in writing of the review determination along with detailed information regarding their due process rights.
The provider may request reconsideration of the AFMC decision within 35 calendar days of the date on the review notification letter. Requests must 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 and Medicaid client 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.
Appeal hearing requests
Medicaid clients may request an appeal of the AFMC decision through the Office of Appeals and Hearings. The appeal request sent to the Appeals and Hearings Section of DHS within 35 calendar days of the date on the denial letter.
Providers may request an appeal of the AFMC decision through the Arkansas Department of Health, Medicaid Provider Appeals Office, 4815 West Markham Street – Slot 31, Little Rock, AR 72205. Please refer to Section 190.000 of the Arkansas Medicaid Provider Manual for more information.