Prior authorization

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?

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.