Learn more about AFMC Review Services

Visit our site

Utilization review services

Helping providers meet quality standards of care

AFMC’s Fort Smith office provides URAC-accredited health utilization management reviews for public and private health plans to ensure all health care services reimbursed are provided in the most efficient manner and are medically necessary. Review staff also helps providers deliver the highest quality of care while at the same time preventing fraud and abuse. Services include:

  • Utilization review – evaluation of the appropriateness and medical need of health care services and procedures according to evidence-based criteria or guidelines, and under the provisions of an applicable health benefits plan
  • Retrospective review – validation of insurance claims against the medical records after services have been performed
  • Prior authorization – determination of whether a service is medically necessary prior to delivery
  • Specialty physician reviewers for review of complex coding and billing issues, disputed denials, and development of criteria for new medical and surgical treatments and procedures
  • Workman’s compensation claim review
  • Quality of care review
  • On-site clinic certifications to ensure proper staff credentials and adherence to all applicable laws and regulations
  • Education and technical assistance to providers regarding review submissions and quality improvement plans

Be sure to visit our health utilization management review page.

Timely filing

In an effort to resolve claims denied for eligibility beginning with dates of service on 10/1/2013, Arkansas Medicaid has made modifications to bypass the timely filing edits. Claims are to be submitted electronically. Providers must verify that an eligibility segment for the dates of service in question is available on file, and verify that a PCP, if required, is on file before the claim is submitted. Providers will have an open window between October 17, 2016 and April 15, 2017 to submit claims. A listing of permissible reasons for qualifying claims and other pertinent information may be obtained from Medicaid. CLAIMS FILED BY PROVIDERS THAT DO NOT QUALIFY UNDER THE IDENTIFIED LISTING WILL BE REVIEWED AND RECOUPED.

AFMC and Medicaid hosted a timely filing webinar on Oct. 7. The webinar video and supporting materials are available at afmc.org/timelyfiling. Answers to questions asked during and after the webinar are also available.

Contact us for more information

Health Information and Privacy Protection

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