Medicaid Retrospective ReviewAFMC reviews a random sample of Medicaid paid claims for medical necessity and quality of care. Cases for this review are selected on a monthly basis and are reviewed by the AFMC area review coordinator (ARC) at your hospital. A case review listing is sent to your hospital by the 5th of each month. The ARC will contact the medical records department to schedule a date for review. Selected records should be available to the ARC when he or she arrives for review. If, during the review, the ARC determines that an admission does not meet admission or length of stay screening criteria, he or she will request that the chart be copied. 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. We frequently are asked why we review cases months or years 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. Providers will be notified in writing of any potential admission or days denials. The provider then has 30 calendar days from the date of the AFMC denial letter to request reconsideration of the denial. If a request is not received within the 30 days, AFMC notifies Medicaid of the denial. Medicaid will then recoup the money that had been paid for this claim. Questions?E-mail: Internal review manager/AFMC ATTENTION! e-mail is not secure and PHI must not be sent via e-mail. |
