Utilization review services
Helping providers meet quality standards of care
AFMC’s Fort Smith office provides 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.
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.