AFMC’s therapy review department performs retrospective utilization and medical necessity reviews on speech, physical and occupational therapy provided to Arkansas Medicaid recipients under age 21. The AFMC therapy review staff includes nurses, therapists (speech, physical, and occupational), physicians, and clerical support staff.
Overview of Medicaid retrospective review of therapy
AFMC reviews a random sample of Medicaid paid claims on a quarterly basis. For each recipient selected for retrospective review, copies are requested for all therapy records from each provider with claims paid during the quarter in review.
The requests are sent to the servicing and/or billing provider at the beginning of each quarter. Once the chart is received and checked in, a review coordinator performs an initial review. All reviews are screened using the promulgated Arkansas Medicaid Therapy Guidelines. If the coordinator cannot approve the review, the chart is referred to the corresponding therapist.
The corresponding therapist may approve the therapy provided or make a recommendation to the physician advisor for possible denial of all or part of the services provided. The physician advisor will review the recommendation and make a final decision to approve or deny. If a denial is issued, the provider will receive correspondence that contains a case-specific rationale of why services do not meet established criteria and directions for requesting reconsideration.
The provider may request reconsideration through AFMC within 35 calendar days from the date of the denial letter. The reconsideration request is tasked to the appropriate therapist and the additional information is reviewed to determine if the services can be approved. If approved, the therapist will reverse the previous denial. If the additional information submitted for reconsideration does not support the medical necessity or claims paid (utilization), the case will be referred to a physician advisor for final determination.
Once a final determination is made by the physician advisor, correspondence is sent notifying the provider as to whether the previous denial was overturned or upheld. The Department of Human Services Division of Medical Services is notified of all final upheld determinations.
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Frequently asked questions
How long do I have to submit the requested information?
As a provider, you will receive a listing of cases selected for review and a record request cover sheet for each therapy discipline. Requested information must be received at AFMC within 30 calendar days of the “date of record request” found on the cover sheet.
Should I send originals or copies?
Please do NOT send originals. Copies of all requested information should be sent, as originals will not be returned.
What is the record request cover sheet?
The record request cover sheet is a letter requesting information on a case that has been selected for review. The requested case letter that contains the child’s name, Medicaid number, AFMC request ID, dates of service, items requested, etc. For a review to be completed, this original cover sheet MUST be completed with the parent/guardian name and address and returned with all requested information. Failure to return the completed cover sheet will delay the review of the submitted record.
What if the child selected is in the protective custody of DHS and the parent/guardian name and address to complete the record request cover sheet is unavailable?
If the child selected is in the protective custody of DHS, the name of the caseworker handling that case and office address is all that is required.
What if I receive a Record Request Cover Sheet for a certain modality (occupational, speech or physical therapy) for a child and that child does not receive that type of therapy?
If a record request cover sheet is received for occupational (OT), speech (ST) or physical therapy (PT), this indicates Medicaid was billed for that specific modality on that child. If provider records do not indicate that OT, ST or PT was provided, an explanation should be submitted along with the record request cover sheet. This explanation should indicate that a billing error was noted.
What do I do if I receive a record request cover sheet for speech, occupational and physical therapy information for the same child?
Each cover sheet will include the child’s name, type of therapy, date range of documentation requested and a list of documentation that must be submitted. If you receive a request for three different therapies on the same child, you must separate the information for each therapy discipline and attach the original cover sheet for the therapy specified to the appropriate chart documentation. Combined charts with more than one cover sheet attached will be returned to the provider for separation. (See the following instructions for proper submission of multiple charts)
For multiple charts on the same child, you may send one copy of the IEP, IFSP or IP. If you wish to do this, please follow these instructions. Please note, a prescription and evaluation for each type of therapy MUST be submitted.
- Attach the AFMC cover sheet to the appropriate chart and submit electronically for review.
- Charts for the same child may be scanned and submitted in one file with a copy of the IEP.
- Be sure to submit all records for the individual child at the same time.
What if a request for records (record request cover sheet(s)) are sent to schools during the third quarter (July) and school is not in session?
AFMC will continue to perform the random selection for charts on a quarterly basis using the following schedule: January, April, July and October. Said requests will be sent electronically to all servicing providers during the first two weeks of each new quarter. AFMC will work with schools as per Arkansas Medicaid’s request to facilitate the submission of the July requests once the school session begins. Please make sure AFMC has the correct email address to serve for all quarters.
What should be included on the treatment/progress notes?
All treatment/progress notes MUST include dates and times for each service you have billed. Also, the full signature and credentials of the providing therapist must be included. The providing therapist MUST sign EACH daily progress note entry with his/her full name and credentials.
Medicaid requires that each treatment/progress note entry MUST contain a specific description of therapy services provided, the activities rendered during each therapy session and a form of measurement.
How should I report test scores?
All test scores must be complete, including all subtests. Scores must be reported as Z scores, T scores, standard scores or percentiles. Percent delay or age equivalency will not be accepted.
If feeding is mentioned during the evaluation, does a swallow study need to be done?
If documentation suggests that a child may have suspected aspiration, a swallow study will be expected to be included in documentation submitted.
What is a valid prescription (DMS-640)?
All prescriptions must be on a DMS-640 form. Compare the dates of service requested with the signature date on the prescription before submitting to AFMC. If the prescription expired during the time frame requested, it will be necessary to send both the old and new prescriptions.
Is a rubber stamp signature valid on the DMS-640?
Rubber stamp signatures will NOT be accepted on the DMS-640 or any other prescription form. The primary care physician (PCP) MUST sign and date the DMS-640/prescription. Prescriptions with rubber stamp signatures will be considered invalid and a denial will be issued.
What is the correct way to make changes to a valid prescription?
Any changes made to a valid prescription must be done with medical integrity. All changes must be made by the PCP/attending physician and must be initialed by that physician, along with the date the change was made. Any changes/alterations made to a valid prescription that does not contain the physician’s initials and the date will be considered invalid.
Is it necessary to complete the entire DMS-640 form?
The provider may complete the referral/treatment boxes, the patient name and the Medicaid ID number. The following information on the DMS-640 must be completed by the physician’s office staff:
- Primary diagnosis/ICD-10 code
- Diagnosis as related to prescribed treatment
- One of the two must be completed with a valid diagnosis pertinent to therapy. Medicaid requires that the individual’s diagnosis must clearly support that the prescribed therapy is medically necessary.
- Prescription block with minutes and duration signed and dated by the PCP or attending physician.
What information do I need to have if I am going to contact AFMC and inquire about a specific chart?
An AFMC request ID will be issued to each specific record that is to be reviewed. This request ID can be found on the record request cover sheet. When inquiring about a specific review, please have the request ID in order for AFMC to directly access that record. Also, please include this request ID when requesting reconsideration or submitting any related information.
If services are denied, may the patient be billed for these services?
As per the Medicaid manual, you may NOT bill a patient for services denied by AFMC on retrospective review.
Will the patient’s PCP receive notification regarding medical necessity denials?
The patient’s PCP will be notified of medical necessity denials. He/she will be provided with the reason for the denial and notified that he/she may be asked to assist in the reconsideration. However, reconsideration requests will only be accepted from the therapy provider.
If a denial is issued and the dates were billed in error, will the denial be overturned and approved if an adjustment request form has been submitted?
No. The dates billed in error will remain denied. However, you may bill for the correct date(s) of service.
How do I ask for reconsideration of denied services?
All reconsideration requests must be received within 35 calendar days of the date of the denial letter. A copy of the denial letter as well as new or additional information not previously submitted must accompany the reconsideration request.
What should I include with my reconsideration?
Please submit information that was not provided previously for reconsideration of the services under review. Also, as stated above, a copy of the denial letter must accompany the reconsideration request.
What do we do if our office moves? Whom should we notify of the new address and contact information?
If your office moves, it is your responsibility to notify AFMC of the change of address and contact information. Please include your provider number on all correspondence. You may mail, email or fax the change to Karla Batey at email@example.com or call (479) 573-7756.
Should I number the pages in each chart I submit?
If you are concerned that pages of a record might be separated and lost, it would be a good idea to hand-number each page of the record before copying. If pages are lost, the numbers would be a good reference for finding the missing pages.
Services that are performed primarily to maintain range of motion or to provide positioning services for the patient do not qualify for occupational therapy services. These services can be provided to the child as part of a home program that can be implemented by the child’s caregivers and do not necessarily require the skilled services of a physical or occupational therapist to perform safely and effectively.
Monday – Friday
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(Lunch is from noon to 1 p.m.)
479-649-8501 or toll free: 877-350-2362
Arkansas Medicaid contact information
If you have questions or wish to sign up to receive the Arkansas Medicaid Official Notices, please contact Medicaid at 501-376-2211, or visit their website.
Utilization review department
AFMC contact information
If you have questions, contact Jarrod McClain 501-212-8605, Karla Batey at 479-573-7756 or use the form below.