Emergency retrospective review process
- Random sample selection for each hospital in Arkansas and bordering hospitals
- Monthly selection made from claims paid the previous month, regardless of date of service (DOS)
- Hospital receives from AFMC:
- ER Cover Sheets
- Copy of hospital “pull list” (retain a copy for your records)
- Hospital provides copy of complete ER record to AFMC:
- UB-04 if available
- Nursing assessment/triage sheet
- Treatment record
- Physician’s H & P examination of patient in the emergency room
- Lab and/or imaging study results
- Record request cover sheet must be stapled on top of each individual record (if sent to AFMC via USPS)
- 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
- If using FedEx, include AFMC’s physical address
- Multiple record requests should be batched together and mailed in one envelope, if being sent to AFMC via USPS or Fed Ex
- 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
- 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. HPE 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.
- Request must be in writing
- Submit further documentation to support medical necessity
- Must include new information not previously submitted
- Copy of denial letter must be attached
- 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.