Extension of benefits (EOB)

On lab, X-ray, physician and outpatient visits

Effective Feb. 1, 2005, AFMC began review of Medicaid EOB requests for clinical, outpatient, laboratory and X-ray services. Requests are considered only after the service(s) have been rendered and a claim is filed and subsequently denied because the patient’s benefit limits have been exhausted. Medicaid has a benefit limit per state fiscal year of:

• $500 for lab and X-ray
• 12 physician visits (in a physician’s office, patient’s home or nursing home)
• 12 outpatient hospital visits (non-emergency ER visits, therapy services and related physician services)
• Providers have the option of filing the EOB request on behalf of their recipients.  See Section 220.000, Benefit Limit

Pathology and radiology referral forms

Pathology referral form – use this form when referring a patient for lab tests

Radiology referral form – use this form when referring a patient for radiology testing

Current EOB review process

229.100 Extension of Benefits for Laboratory and X-Ray, Physician Office and Outpatient Hospital Services 2-1-05

• Requests for extension of benefits for laboratory and X-ray, physician and outpatient services must be mailed to Arkansas Foundation for Medical Care (AFMC), Attn: EOB Review, 5111 Rogers Ave. Suite 476, Fort Smith, AR 72903 or P.O. Box 180001, Fort Smith, AR 72918-0001
  • i.Requests for extension of benefits are considered only after a claim is filed and is denied because the patient’s benefit limits are exhausted.
  • ii.Submit with the request a copy of the Medical Assistance Remittance and Status Report reflecting the claim’s denial for exhausted benefits. Do not send a claim.
• A request for extension of benefits must be received by AFMC within 90 calendar days of the date of benefits-exhausted denial.
  • i.Requests for extension of benefits are considered only after a claim is filed and is denied because the patient’s benefit limits are exhausted.
  • ii.Submit with the request a copy of the Medical Assistance Remittance and Status Report reflecting the claim’s denial for exhausted benefits. Do not send a claim.

229.110 Completion of Request Form DMS-671, “Request For Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services” 7-1-07

Requests for extension of benefits for clinical services (physician’s visits), outpatient services (hospital outpatient visits), laboratory services (lab tests) and X-ray services (X-ray, ultrasound, electronic monitoring — EEG, EKG. etc.), must be submitted to AFMC for consideration. Consideration of requests for extension of benefits requires correct completion of all fields on the Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray (form DMS-671). View the manual. View or print form DMS-671.) Complete instructions for accurate completion of form DMS- 671 (including indication of required attachments) accompany the form. All forms are listed and accessible in Section V of each Provider Manual.

Section II-46 Physician/Independent Lab/CRNA/Radiation Therapy Center Section II 229.120 Documentation Requirements 2-1-05

A. To request extension of benefits for any benefit-limited service, all applicable records that support the medical necessity of extended benefits are required. B. Documentation requirements are as follows:

i. Clinical records must:

a) Be legible and include records supporting the specific request

b) Be signed by the performing provider

c) Include clinical, outpatient and/or emergency room records for dates of service in chronological order

d) Include related diabetic and blood pressure flow sheets

e) Include a current medication list for the date of service

f) Include the obstetrical record related to a current pregnancy when applicable

g) Include clinical indication for laboratory and X-ray services ordered with a copy of orders for laboratory and X-ray services signed by the physician

ii. Laboratory and radiology reports must include:

a) Clinical indication for laboratory and X-ray services ordered

b) Signed orders for laboratory and radiology services

c) Results signed by the performing provider

d) Current and all previous ultrasound reports, including biophysical profiles and fetal non-stress tests when applicable

229.130 Administrative Reconsideration of Extensions of Benefits Denial 2-1-06

A. A request for administrative reconsideration of an extension of benefits denial must be in writing and sent to AFMC within 30 calendar days of the denial. The request must include a copy of the denial letter and additional supporting documentation pursuant to section 229.120.

B. The deadline for receipt of the reconsideration request will be enforced pursuant to sections 190.012 and 190.013 of this manual. A request received by AFMC within 35 calendar days of a denial will be deemed timely. A request received later than 35 calendar days gives rise to a rebuttable presumption that it is not timely.

229.140 Appealing an Adverse Action 2-1-06

Please see section 190.000 et al. for information regarding administrative appeals.

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.

Questions?

Telephone: 479-649-8501, Option 1
Fax: 479-649-0799

Extension of benefits (EOB) FAQs