Prior authorization

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

Medicaid requires that some surgical procedures be authorized by AFMC prior to the performance of the procedure. Procedures can require authorization regardless of whether they are performed on an inpatient or outpatient basis.

To request authorization, call AFMC at 800-426-2234 between 8:30 a.m.-12 p.m. and 1-5 p.m. Monday through Friday, with the exception of holidays.

See “Procedure for Obtaining Prior Authorization” in the Arkansas Medicaid Provider Manual, Section 241.000, page II-77.

CPT codes that require prior authorization by AFMC can be found in your Arkansas Medicaid Provider Manual. (Section 241.000, page II-77.) These manuals, as well as the manual updates, are disseminated to all Arkansas Medicaid providers by Medicaid.

The following information is required for AFMC to conduct a review for medical necessity of a prior-authorization procedure:

  1. Patient name and address (including zip code)
  2. Patient birthdate
  3. Patient Medicaid number
  4. Admission and procedure date
  5. Hospital or ambulatory surgery center name
  6. Facility Medicaid provider number
  7. Medicaid provider number of physician performing procedure
  8. CPT code for procedure(s)
  9. Principal diagnosis and any other diagnoses
  10. Signs/symptoms of illness
  11. Medical indication for justification of procedure(s)

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 pre-certification number: 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.

Questions?

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Authorization for procedures, assistant surgeons or length of stays indicates that AFMC has determined medical necessity. It does not indicate that the patient is eligible for Medicaid coverage. The provider is responsible for verifying patient eligibility for the dates of service.

Learn more about the Medicaid Fairness Act

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Health Information and Privacy Protection

How AFMC protects you

AFMC respects your concerns about personal data protection and value our relationship with you. AFMC complies with federal and state laws, also an internal compliance program to protect the privacy of medical records, personal health information (PHI), and personal identifiable information (PII). AFMC implements a set of processes and system controls designed to ensure security of your privacy regulated by the Federal Information Security Management Act (FISMA). We put continuous efforts into monitoring potential risk by conducting audits, risk management, security planning and other FISMA related best practices. The Standards of Conduct articulates AFMC’s commitment to follow applicable federal and state laws and regulations, including the following: Title XVIII of the Social Security Act; Medicare regulations found in 42 C.F.R., sections 422 and 423; Patient Protection and Affordable Care Act (PPACA); Health Insurance Portability and Accountability Act (HIPAA) and as modified by HITECH Act; False Claims Act (FCA) and the Federal Criminal False Claims statutes; NIST Special Publication 800-26, Department of Defense (DoD) Policy 8500; Director of Central Intelligence Directive (DCID) 6/3; ISO/IEC Standard 17799; General Accounting Office (GAO) Federal Information System Controls Audit Manual (FISCAM); and Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) Core Security Requirements.

How to protect yourself

AFMC will protect your privacy as described in this Privacy Statement, however, you should keep in mind that if you voluntarily disclose personal information, especially confidential health information, it is possible that despite our efforts, information may be accessible by others. You can help guard against this by:

  • Enabling security features on personal mobile devices
  • Use strong passwords with your laptop and mobile accounts
  • Safely dispose of personal information (mail, old hard drives and computers)
  • Ensure that personal computers have the latest security updates to decrease risk
  • Keeping hard copy of sensitive information stowed away in secure cabinet or briefcase
  • Don’t overshare information through social networking
  • Be conscious of web security (internet browser settings)
  • Be conscious of your surrounding when carrying sensitive information