Assistant surgeon prior authorization

For medical payment to be made to an assistant surgeon, the physician who wishes to use an assistant surgeon must obtain prior authorization from AFMC. See Section 251.110 of the Arkansas Medicaid Provider Manual for assistant surgeon prior authorization instructions. See Section 261.000 in the Arkansas Medicaid Provider Manual for prior authorization instructions. This provision applies to all surgery.” (See Section 241.000, page II-77, in the Arkansas Medicaid Provider Manual, regarding Assistant Surgery program coverage)

AFMC precertification phone number: 800-426-2234
AFMC phone review hours: 8:30 a.m.-12 p.m. and 1 p.m.-5 p.m. Monday through Friday, with the exception of holidays. All calls are monitored for quality assurance purposes.

When calling AFMC to obtain authorization for an assistant surgeon, the following information will be required:

1. Patient name and address (including zip code)
2. Patient birth date
3. Patient Medicaid number
4. Admission and procedure date
5. Hospital or ambulatory surgery center name
6. Facility Medicaid provider number
7. Medicaid provider number and name of primary surgeon
8. Office phone number of primary surgeon
9. CPT code for procedure(s)
10. Principal diagnosis and any other diagnoses
11. Signs/symptoms of illness
12. Medicaid provider number and name of assistant surgeon
13. A medical explanation of why an assistant surgeon is required — for instance, the complexity of the procedure requires two surgeons to perform the procedure simultaneously

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.

Reconsideration requests

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 beneficiary will be notified in writing of the review determination. Reconsideration is available only once per prior authorization request.

Fair hearing requests

The Medicaid beneficiary 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.

Questions?

Authorization for procedures, assistant surgeons or length of stays indicates that AFMC has determined medical necessity. It does not indicate that the patient is eligible for Medicaid coverage. The provider is responsible for verifying patient eligibility for the dates of service.