Emergency retrospective review process

Medicaid Utilization Management Program, Emergency Room and Pre-certification team photo

  1. Random sample selection for each hospital in Arkansas and bordering hospitals
  2. Monthly selection made from claims paid the previous month, regardless of date of service (DOS)
  3. Hospital receives packet from AFMC
    • Salmon-colored cover sheet
    • Copy of hospital “pull list” (retain a copy for your records)
    • Instruction sheet
    • Preaddressed labels to AFMC
  4. Hospital provides copy of complete ER record to AFMC
    • UB-92
    • Nursing assessment/triage sheet
    • Treatment record
    • Physician’s H & P examination of patient in the emergency room
    • Lab and/or imaging study results
  5. Record request cover sheet must be stapled on top of each individual record
    • Do not stamp or write on bottom of cover sheet
    • Original cover sheet and complete record must be returned in order for review to be performed.
    • Records received without cover sheet may be returned unreviewed
    • A denial will be issued if the record is not received at AFMC within the required time frame due to lack of documentation to support the medical necessity of the emergency room service
    • Second request for missing documentation will not be made
  6. Mail record to AFMC using the mailing label provided; if using FedEx, include AFMC’s physical address
  7. Multiple record requests should be batched together and mailed in one envelope
  8. If records are not received at AFMC within 15 calendar days of the date of the request, a second request will be mailed to the hospital
  9. If records are not received at AFMC within 30 calendar days of the date of the first/original request, a denial will be issued for lack of documentation to support medical necessity of the emergency service

Note: The information on the top right hand corner of the record request cover sheet is the information that was billed by the facility. EDS paid the claim based on the information billed by the facility. If a facility receives a record request cover sheet with information that was billed/paid incorrectly, the facility must return the record request cover sheet with an explanation of the billing error to AFMC, to the attention of Jackie Parker, RN, internal review manager. The facility should not send a record to AFMC that was not requested per the record request cover sheet.

Reconsideration requests

  1. Request must be in writing
  2. Submit further documentation to support medical necessity
  3. Must include new information not previously submitted
  4. Copy of denial letter must be attached
  5. Request must be received at AFMC within 35 calendar days of the date of denial letter

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.

AFMC ReviewPoint® is an alternate method of submitting requests and/or medical records.

Questions?

  • This field is for validation purposes and should be left unchanged.

Learn more about the Medicaid Fairness Act

Go here

Learn more about AFMC ReviewPoint®

Go here
Health Information and Privacy Protection

How AFMC protects you

AFMC respects your concerns about personal data protection and value our relationship with you. AFMC complies with federal and state laws, also an internal compliance program to protect the privacy of medical records, personal health information (PHI), and personal identifiable information (PII). AFMC implements a set of processes and system controls designed to ensure security of your privacy regulated by the Federal Information Security Management Act (FISMA). We put continuous efforts into monitoring potential risk by conducting audits, risk management, security planning and other FISMA related best practices. The Standards of Conduct articulates AFMC’s commitment to follow applicable federal and state laws and regulations, including the following: Title XVIII of the Social Security Act; Medicare regulations found in 42 C.F.R., sections 422 and 423; Patient Protection and Affordable Care Act (PPACA); Health Insurance Portability and Accountability Act (HIPAA) and as modified by HITECH Act; False Claims Act (FCA) and the Federal Criminal False Claims statutes; NIST Special Publication 800-26, Department of Defense (DoD) Policy 8500; Director of Central Intelligence Directive (DCID) 6/3; ISO/IEC Standard 17799; General Accounting Office (GAO) Federal Information System Controls Audit Manual (FISCAM); and Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) Core Security Requirements.

How to protect yourself

AFMC will protect your privacy as described in this Privacy Statement, however, you should keep in mind that if you voluntarily disclose personal information, especially confidential health information, it is possible that despite our efforts, information may be accessible by others. You can help guard against this by:
  • Enabling security features on personal mobile devices
  • Use strong passwords with your laptop and mobile accounts
  • Safely dispose of personal information (mail, old hard drives and computers)
  • Ensure that personal computers have the latest security updates to decrease risk
  • Keeping hard copy of sensitive information stowed away in secure cabinet or briefcase
  • Don’t overshare information through social networking
  • Be conscious of web security (internet browser settings)
  • Be conscious of your surrounding when carrying sensitive information