Prosthetics

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 i

nclude 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 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 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.

AFMC review process

A registered nurse reviewer initially screens the prior authorization requests. If the documentation submitted supports medical necessity, the nurse reviewer may approve the prior authorization.

If the nurse reviewer is unable to approve medical necessity of the requested service, the review is referred to a physician advisor for determination. AFMC utilizes actively practicing physicians who are licensed in the state of Arkansas to review the prior authorization requests. The physician advisor uses his/her medical judgment, in accordance with established Medicaid policies, to review medical necessity of the requested equipment.

Review notifications

Upon completion of each prior authorization request, AFMC provides written notification of the review determination to the requesting provider and the Medicaid beneficiary.

Approval notifications – include each procedure code/modifiers and units approved along with the authorization number for billing

Denial notifications – include case-specific clinical rationale and detailed information about how to appeal the determination, including the time frame allowed for submission and the requirement to provide additional information to support the medical necessity of the service denied

Due process rights

If AFMC is unable to fully approve any requested service, all applicable parties are notified in writing of the review determination along with detailed information regarding their due process rights.

Reconsideration requests

The provider may request reconsideration of the AFMC decision within 35 calendar days of the date on the review notification letter. Requests must 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 and Medicaid beneficiary 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.

Appeal hearing requests

Medicaid beneficiaries may request an appeal of the AFMC decision through the Office of Appeals and Hearings. The appeal request sent to the Appeals and Hearings Section of DHS within 35 calendar days of the date on the denial letter.

Providers may request an appeal of the AFMC decision through the Arkansas Department of Health, Medicaid Provider Appeals Office, 4815 West Markham Street – Slot 31, Little Rock, AR 72205.  Please refer to Section 190.000 of the Arkansas Medicaid Provider Manual for more information.