Current through Register Vol. 49, No. 9, September, 2024
SECTION II -VISUAL CARE
200.000
VISUAL CARE GENERAL
INFORMATION
201.000
Arkansas Medicaid Participation Requirements for Visual Care Providers
Visual Care Program providers meeting the following criteria
are eligible for participation in the Arkansas Medicaid Program:
A. Provider must be licensed by the State
Board of Optometry to practice in his or her state. A current copy of the
optometrist's license must be submitted with the provider application for
participation. Subsequent licensure must be provided when issued.
1. Subsequent license renewal must be
forwarded to Provider Enrollment within 30 days of issue. If the renewal
documents have not been received within the 30-day deadline, the provider will
have an additional and final 30 days to comply.
2. Failure to ensure that current licensure
is on file with Provider Enrollment will result in termination from the
Arkansas Medicaid Program.
B. Provider must be enrolled in the Title
XVIII (Medicare) Program.
C.
Provider must complete a provider application (Form DMS-652), a Medicaid
contract (Form DMS-653) and a Request for Taxpayer Identification Number and
Certification (Form W-9). View or print the provider
application (Form DMS-652), the Medicaid contract (Form DMS-653) and the
Request for Taxpayer Identification Number and Certification (Form
W-9).
D.
Enrollment as a Medicaid provider is conditioned upon approval of a completed
provider application and the execution of a Medicaid provider contract. Persons
and entities that are excluded or debarred under any state or federal law,
regulation or rule are not eligible to enroll, or to remain enrolled, as
Medicaid providers.
Visual Care Providers in Arkansas and Bordering
States
Visual Care Program providers in Arkansas and the bordering
states of Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas will
be enrolled as routine services providers.
Routine Services Providers
A. Provider will be enrolled in the program
as a regular provider of routine services.
B. Reimbursement will be available for all
visual care services covered in the Arkansas Medicaid Program.
C. Claims must be filed according to Section
240.000 of this manual. This
includes assignment of ICD-9-CM and HCPCS codes for all services rendered.
Visual Care Providers in Non-Bordering
States
All Visual Care Program providers in non-bordering states may
be enrolled only as limited services providers.
Limited Services Providers
A. Providers will be enrolled in the program
to provide prior authorized or emergency services only.
"Emergency services" are defined as inpatient or outpatient
hospital services that a prudent layperson with an average knowledge of health
and medicine would reasonably believe are necessary to prevent death or serious
impairment of health and which, because of the danger to life or health,
require use of the most accessible hospital available and equipped to furnish
those services. Source: 42 U.S. Code of Federal Regulations §
422.2 and §
424.101.
"Prior authorized services" are those that are medically
necessary and not available in Arkansas. Each request for these services must
be made in writing, forwarded to the Utilization Review Section and approved
before the service is provided. An Arkansas Medicaid Provider Contract must be
signed before reimbursement can be made. A provider number will be assigned
upon receipt and approval of the provider application and Medicaid contract.
View or print the Division of Medical Services, Utilization
Review Section contact information.
B. Limited Services provider claims will be
manually reviewed prior to processing to ensure that only emergency or prior
authorized services are approved for payment. These claims should be mailed to
the Arkansas Division of Medical Services, Program Communications Unit.
View or print the Division of Medical Services, Program
Communications Unit contact
information.
201.100
Group Providers of Visual Care
Services
Group providers of visual care services must meet the following
criteria in order to be eligible for participation in the Arkansas Medicaid
Program.
In situations where an optometrist is a member of a group, each
individual optometrist and the group must both enroll according to the
following criteria:
A. Each individual
optometrist in the group must enroll following the criteria established in
Section 201.000.
B. The group must complete a provider
application and Medicaid contract as an Arkansas Medicaid provider of visual
care services. See Section
I of this manual. Enrollment as a
Medicaid provider is conditioned upon approval of a completed provider
application and the execution of a Medicaid provider contract. Persons and
entities that are excluded or debarred under any state or federal law,
regulation or rule are not eligible to enroll, or to remain enrolled, as
Medicaid providers.
All group providers are "pay to" providers
only. The service must be performed and billed by a
licensed and enrolled optometrist with the group.
202.000 Visual Care Records Providers are
Required to Keep Visual care providers are required to keep the following
records and, upon request, must immediately furnish the records to authorized
representatives of the Division of Medical Services, the state Medicaid Fraud
Control Unit, representatives of the Department of Health and Human Services
and the Centers for Medicare and Medicaid Services:
A. History and visual care examination on
initial visit.
B. Chief complaint
on each visit.
C. Tests and
results.
D. Diagnosis.
E. Treatment, including
prescriptions.
F. Signature or
initials of visual care provider after each visit.
G. Copies of hospital and/or emergency room
records that are available to disclose services.
1. All records must be kept for five (5)
years from the ending date of service or until all audit questions, appeal
hearings, investigations or court cases are resolved, whichever is longer.
Failure to furnish these records upon request may result in sanctions being
imposed.
2. All documentation must
be immediately made available to representatives of the Division of Medical
Services at the time of an audit by the Medicaid Field Audit Unit. All
documentation must be available at the provider's place of business. When a
recoupment is necessary, no more than thirty (30) days will be allowed after
the date of the recoupment notice in which additional documentation will be
accepted. Additional documentation will not be accepted after the 30 days
allowed after recoupment.
3. Visual
Care providers furnishing any Medicaid-covered good or service for which a
prescription is required by law, by Medicaid rule, or both, must have a copy of
the prescription for such good or service. The Visual Care provider must obtain
a copy of the prescription within five (5) business days of the date the
prescription is written.
4. The
Visual Care provider must maintain a copy of each relevant prescription in the
Medicaid beneficiary's records and follow all prescriptions and care
plans.
5. The Visual Care provider
must adhere to all applicable professional standards of care and
conduct.
216.230
Administrative Reconsideration
of Extensions of Benefits Denial
A request for administrative reconsideration of an extension of
benefits denial must be in writing and sent to AFMC within 30 calendar days of
the denial. The request must include a copy of the denial letter and additional
supporting documentation pursuant to section
221.100.
The deadline for receipt of the reconsideration request will be
enforced pursuant to sections
190.012 and
190.013 of this manual. A request
received by AFMC within 35 calendar days of a denial will be deemed timely. A
request received later than 35 calendar days gives rise to a rebuttable
presumption that it is not timely.
216.240
Appealing an Adverse Action
Please see section
190.000 et al for information
regarding administrative appeals.
221.100
AFMC Extension of Benefits
Review Process
The following is a step-by-step outline of AFMC's extension of
benefits review process:
A. Requests
received via mail are screened for completeness and researched to verify the
beneficiary's eligibility for Medicaid when the service was provided and to
determine whether the claim has already been paid.
B. The documentation submitted is reviewed by
a nurse. If, in the judgment of the nurse the documentation supports medical
necessity, he or she may approve the request. An approval letter is computer
generated and mailed to the provider the following day.
C. If the nurse reviewer determines the
documentation does not justify the service or it appears that the service is
not medically necessary, he or she will refer the case to the appropriate
physician advisor for a decision.
D. The physician reviewer's rationale for
approval or denial is entered into the computer review system and the
appropriate notification is created. If services are denied for medical
necessity, the physician reviewer's reason for the decision is included in the
denial letter. A denial letter is mailed to the provider and the beneficiary
the following work day.
E.
Providers may request administrative reconsideration of an adverse decision or
they can appeal as provided in section
190.003 of this manual.
F. If the denial is because of incomplete
documentation, but complete documentation that supports medical necessity is
submitted with the reconsideration request, the nurse may approve the extension
of benefits without referral to a physician advisor.
G. If the denial is because there is no proof
of medical necessity or the documentation does not allow for approval by the
nurse, the original documentation, reason for denial and new information
submitted will be referred to a different physician advisor for
reconsideration.
H. All parties
will be notified in writing of the outcome of the reconsideration.
222.000
Duration of
Authorization
Medical assistance prior authorizations are valid for 180 days
from date of approval, provided the patient remains eligible for services.
Prior authorization does not guarantee payment unless the patient remains
eligible.
The doctor's office will be responsible for verifying
eligibility for the dates in which services are
provided. The patient is responsible for telling the doctor that
he or she is a Medicaid beneficiary when making the first appointment.
The doctor should always keep a copy of the services authorized
with the prior authorization control number and a copy of each claim submitted.
If the treatment has not been completed in this period of time, send a new
request for authorization for the portion of the plan not completed. A new
prior authorization control number may be issued under prevailing
policies.
