Hyperalimentation

Both parenteral and enteral (sole source) nutrition therapy services are covered under the Arkansas Medicaid Hyperalimentation Program. In general, the term “hyperalimentation,” when used in this provider manual, refers to both parenteral and enteral (sole source) nutrition therapy.

AFMC performs prior authorization reviews for:

• Enteral nutrition
• Equipment and supplies for enteral (sole source) nutrition therapy
• Total parenteral nutrition

Please refer to Section II of the Medicaid Hyperalimentation Manual found on Arkansas Medicaid’s website for complete program information.

Prior authorization

Requests for prior authorization of the above items must be submitted to AFMC on the Request for Prior Authorization and Prescription Form DMS-2615.

Consideration of prior authorization requests by AFMC requires correct completion of all fields on the request form. The documentation submitted with the prior authorization request must support the medical necessity of the requested nutritional therapy. In some cases, AFMC may request additional information (i.e., original prescription, records from the hospitalization initiating nutritional therapy, nutritional assessment to establish medical necessity for nutritional therapy, etc.).

Prior authorization requests may be submitted via hardcopy via U.S. Mail, FedEx, UPS, etc., or electronically through AFMC ReviewPoint®.

For U.S. Mail:
AFMC
P.O. Box 180001
Fort Smith, AR 72918-0001

For FedEx, UPS or other such carriers:
AFMC
5111 Rogers Avenue, Suite 476
Fort Smith, AR 72903

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

Preapprovals

When an eligible Medicaid beneficiary is discharged from the inpatient setting with the continuation of hyperalimentation services in the home, a provider may request a preapproval for hyperalimentation prior to the anticipated discharge date. The request for preapproval must be faxed to AFMC at 479-649-0776.

When approved, a prior authorization number will be assigned and will be effective for 30 days. The provider must not bill for hyperalimentation services prior to the date of discharge or bill for services on the same dates of service as the inpatient stay.

If the beneficiary is not discharged within the 30 days, the preapproval will be void.

When continuation of the therapy is required past the initial 30-day preapproval, the provider must submit a recertification for prior authorization request for continuation of the therapy, with a prescription signed by the prescribing physician, prior to the end date of the pre-approval.

A preapproval of hyperalimentation services does not guarantee payment.

AFMC review process

A registered nurse reviewer initially screens the prior authorization requests. If the documentation submitted supports medical necessity, the nurse reviewer may approve the prior authorization.

If the nurse reviewer is unable to approve medical necessity of the requested service, the review is referred to a physician advisor for determination. AFMC utilizes actively practicing 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 requested equipment.

Review notifications

Upon completion of each prior authorization request, AFMC provides written notification of the review determination to the requesting provider and the Medicaid beneficiary.

Approval notifications – include each procedure code/modifiers and units approved along with the authorization number for billing

Denial notifications – include case-specific clinical rationale and detailed information about how to appeal the determination, including the time frame allowed for submission and the requirement to provide additional information to support the medical necessity of the service denied

Due process rights

If AFMC is unable to fully approve any requested service, all applicable parties are notified in writing of the review determination along with detailed information regarding their due process rights.

Reconsideration requests

The provider may request reconsideration of the AFMC decision within 35 calendar days of the date on the review notification letter. Requests must 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 and Medicaid beneficiary 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.

Appeal hearing requests

Medicaid beneficiaries may request an appeal of the AFMC decision through the Office of Appeals and Hearings. The appeal request sent to the Appeals and Hearings Section of DHS within 35 calendar days of the date on the denial letter.

Providers may request an appeal of the AFMC decision through the Arkansas Department of Health, Medicaid Provider Appeals Office, 4815 West Markham Street – Slot 31, Little Rock, AR 72205.  Please refer to Section 190.000 of the Arkansas Medicaid Provider Manual for more information.

Contact us

If you have further questions on specific reviews, please contact the AFMC Hyperalimentation Review Department at 479-573-7746.