Hyperalimentation

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

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.

Effective Oct. 1, 2006, 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 (which can be found on Arkansas Medicaid’s Web site 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 must be mailed to:

AFMC
ATTN: Ami Winters
P.O. Box 180001
Fort Smith, AR 72918-0001

Approvals

When a PA request is approved, a prior authorization control number will be assigned by AFMC. Prior authorization approvals are authorized for a maximum of six months (180 days) or for the life of the prescription, whichever is shorter. If the prescribing physician documents the beneficiary’s condition is chronic and unlikely to change, a prior approval may be authorized for a maximum of 12 months. The effective date of the prior authorization will be the date the patient will begin therapy or the day following the last day of the previous authorization approval.

Within 30 working days before the end of currently authorized nutrition services, the provider must obtain a new prescription. If applicable, the provider must prepare and submit a new Request for Prior Authorization and Prescription Form DMS-2615 signed by the prescribing physician.

Pre-approvals

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 pre-approval for hyperalimentation prior to the anticipated discharge date. The request for pre-approval 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 pre-approval will be void.

When continuation of the therapy is required past the initial 30-day pre-approval, 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 pre-approval of hyperalimentation services does not guarantee payment.

Denials

For denied cases, AFMC will mail a letter containing case-specific rationale that explains why the request was not approved to the requesting provider and to the Medicaid beneficiary within 30 working days of receipt of the prior authorization request.

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.

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

Contact us

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

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Learn more about the Medicaid Fairness Act

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Learn more about AFMC ReviewPoint®

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