Services provided include durable medical equipment, including specialized wheelchairs, wheelchair seating systems, specialized rehabilitation equipment and the augmentative communication device. Other items that may be covered include medical supplies, nutritional formulas, diapers and underpads, prosthetic devices and orthotic appliances.
AFMC performs prior authorization reviews for:
- Respiratory and diabetic equipment
- Some medical supplies (insulin infusion pump supplies, drug infusion catheter and pump supplies, compression burn garments)
- Enteral nutrition infusion pump and pump supply kit for individuals under age 21
- MIC-KEY skin level gastrostomy tube (Mic-Key Button) and supplies for individuals under age 21
- Durable medical equipment, excluding wheelchairs, wheelchair seating systems and wheelchair repairs
- Orthotic appliances
- Prosthetic devices
- Specialized rehabilitation equipment
- Augmentative communication devices
Please refer to Section II of the Medicaid Prosthetics Manual on Arkansas Medicaid’s Web site for complete program information and to determine which procedure codes require prior authorization.
Requests for prior authorization of the above items must be submitted to AFMC on the Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components Form (AFMC-103). This form can be found here.
Consideration of prior authorization requests by AFMC requires correct completion of all fields on the request form. The prior authorization request form must contain current medical documentation of the necessity of the required prosthetics. If necessary, AFMC may request additional information. Requests must be mailed to:
Attention: Ami Winters
P.O. Box 180001
Fort Smith, AR 72918-0001
When a PA request is approved, a prior authorization control number will be assigned by AFMC. The effective date of the prior authorization will be the date on which the beneficiary’s physician prescribed prosthetics services or the day following the last day of the previously prior authorized time period, whichever comes last.
Within 30 working days before the end of the currently authorized prosthetics services, the provider must obtain a new prescription. If applicable, the provider must prepare and submit a new Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components (form AFMC-103) signed by the prescribing physician.
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.
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.
If you have further questions on specific reviews, please contact the AFMC Prosthetics Review Department at 479-573-7746 or use the form below.