Medicaid Utilization Management Program (MUMP)

The Arkansas Department of Human Services instituted the Medicaid Utilization Management Program (MUMP) to determine reimbursement for lengths of stay for all inpatient acute care/general and rehabilitative hospital services. Services performed in lone standing psychiatric facilities are excluded.

AFMC performs the review under contract to Arkansas Medicaid.

AFMC pre-certification: Call 800-426-2234
AFMC phone review hours: 8:30 a.m.-12 p.m. and 1-5 p.m. Monday through Friday, with the exception of holidays. All calls are monitored for quality assurance purposes.

Groups affected

All age groups and Medicaid eligibility categories, except for recipients under age 1, are affected by this policy. The policy includes all acute care/general and rehabilitative hospitals, in or out-of-state. Please see item 5, Transmittal No. 52, for the procedure to follow when a child’s first birthday occurs during an inpatient stay.

Instructions for applying the MUMP procedures are detailed in the Arkansas Medicaid Provider Manual. (Section 212.520, page II-23)

Telephone procedure

The procedure for the MUMP telephone review with AFMC is as follows:

1. Patient name and address (including zip code)
2. Patient birth date
3. Patient Medicaid number
4. Admission date
5. Hospital name
6. Hospital Medicaid provider number
7. Attending physician Medicaid provider number
8. Principal diagnosis and other diagnoses influencing this stay
9. Surgical procedures performed or planned
10. The number of days being requested for continued inpatient care
11. All available medical information justifying or supporting the necessity of continued stay in the hospital

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.

Questions?

AFMC pre-certification: Call 800-426-2234