AFMC reviews a random sample selection of Arkansas Medicaid inpatient hospital stays for medical necessity of all paid days, quality of care and billing errors. This random sample selection is made from paid claims data on a monthly basis and a case review listing is sent to hospitals by the fifth day of each month. Hospitals are asked to submit copies of the medical record for each of the selected cases via ReviewPoint®. Other methods of chart submission are available. Please call the AFMC’s Processing Department at 479-649-8501, option 1 to discuss other available options. Hospitals may submit paper chart copies; however, according to Arkansas Medicaid, chart copying costs are figured into the hospital’s per diem reimbursement rate and no additional reimbursement for chart copies will be made.
A registered nurse Clinical Services Specialist initially reviews the inpatient stay. If the documentation submitted supports medical necessity, the Clinical Services Specialist may approve the service(s).
If during the initial review, it is determined that the hospital inpatient stay does not meet admission or length of stay screening criteria, or there is a quality-of-care concern, the case is referred for physician review.
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 hospital inpatient stay.
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.
AFMC is frequently asked why cases are reviewed months after the admission occurred. There are many reasons why hospitals do not file claims as soon as the patient is discharged; however, AFMC selects cases for review from the claims paid in the previous month.
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 then has 35 calendar days from the date of the AFMC denial letter to request reconsideration of the denial. If the initial denial is upheld on reconsideration or if reconsideration is not requested within the required timeframe, AFMC notifies Medicaid of the denial to determine if recoupment of the money that had been paid for the claim is required.
Reconsiderations can be submitted utilizing the same methods as the initial request; however, the preferred method is electronically through ReviewPoint®.
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.