Retrospective review

Retro-respective review team photo

AFMC reviews a random sample selection of Medicaid inpatient hospital stays for medical necessity of all paid days, quality of care, and billing errors. This random sample selection is made from paid claims data on a monthly basis and a case review listing is sent to hospitals by the 5th of each month. Hospitals are asked to submit copies of the medical record for each of the selected cases via AFMC ReviewPoint®. Other methods of chart submission are available. Please call the AFMC Processing Department (479-573-7770) discuss other available options. Hospitals may submit paper chart copies, however, according to Medicaid, chart copying costs are figured into the hospital’s per diem reimbursement rate and no additional reimbursement for chart copies will be made.

If, during the initial review, it is determined that the hospital inpatient stay does not meet admission or length of stay screening criteria, or there is a quality of care concern, the case is referred for physician review.

AFMC is frequently asked why cases are reviewed months after the admission occurred. There are many reasons why hospitals do not file claims as soon as the patient is discharged; however, AFMC selects cases for review from the claims paid in the previous month.

AFMC ReviewPoint® is an alternate method of submitting requests and/or medical records.

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

The provider then has 30 calendar days from the date of the AFMC denial letter to request reconsideration of the denial. If the initial denial is upheld on reconsideration or if reconsideration is not requested within the required timeframe,  AFMC notifies Medicaid of the denial to determine if recoupment of the money that had been paid for the claim is required.

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.

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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