ProstheticsDue to a request from Medicaid, our Prior Authorization (PA) number formatting has changed, effective 7/1/10. All AFMC PA numbers now begin with the letter A. 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 include medical supplies, nutritional formulas, diapers and underpads, prosthetic devices and orthotic appliances. AFMC performs prior authorization reviews for:
Please refer to Section II of the Medicaid Prosthetics Manual on Arkansas Medicaid’s Web site for complete program information and to determine which procedure codes require prior authorization. Prior AuthorizationRequests 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. Requests must be mailed to: Attention: Ami Winters ApprovalsWhen a PA request is approved, a prior authorization control number will be assigned by AFMC. The effective date of the prior authorization will be the date on which the beneficiary’s physician prescribed prosthetics services or the day following the last day of the previously prior authorized time period, whichever comes last. Within 30 working days before the end of the currently authorized prosthetics services, the provider must obtain a new prescription. If applicable, the provider must prepare and submit a new Prescription and Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components (form AFMC-103) signed by the prescribing physician. DenialsFor denied cases, AFMC will mail a letter containing case-specific rationale that explains why the request was not approved to the requesting provider and to the Medicaid beneficiary within 30 working days of receipt of the prior authorization request. Reconsideration requestsThe provider may request reconsideration of the denial within 35 calendar days of the denial date. Requests must be made in writing and 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 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. However, if the denial is upheld during the reconsideration process, the provider may submit a new prior authorization request, for different dates of service, provided new supporting documentation is available. A subsequent prior authorization request will not be reviewed if it contains the same documentation submitted with the previous authorization and reconsideration requests. Fair hearing requestsThe Medicaid beneficiary may request a fair hearing of a denied review determination made by either Utilization Review, Department of Human Services (DHS) or the Arkansas Foundation for Medical Care (AFMC). The fair hearing request must be in writing and sent to the Appeals and Hearings Section of DHHS within 35 calendar days of the date on the denial letter. Providers may refer to section 190.000 for information regarding provider appeals through the Medicaid Fairness Act. Fair Hearing requests must be sent to the Department of Human Services Appeals and Hearings Section, P.O. Box 1437, Slot N401 Little Rock, AR 72203-1437. Contact usIf you have further questions on specific reviews, please contact the AFMC Prosthetics Review Department at 479-573-7746 or awinters@afmc.org ATTENTION! e-mail is not secure and PHI must not be sent via e-mail. |
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