Current through Register Vol. 49, No. 9, September, 2024
Arkansas Medicaid Health Care Providers - Rehabilitative
Services for Persons with Physical Disabilities Provider Manual Update
Transmittal #38 Page 2
Section 240.000 is included to correct a
minor grammatical error.
Paper versions of this update transmittal have updated pages
attached to file in your provider manual. See Section I for instructions on
updating the paper version of the manual. For electronic versions, these
changes have already been incorporated.
If you need this material in an alternative format, such as
large print, please contact our Americans with Disabilities Act Coordinator at
(501) 682-6789 or 1-877-708 -8191. Both telephone numbers are voice and
TDD.
If you have questions regarding this transmittal, please
contact the EDS Provider Assistance Center at 1 - 800-457-4454 (Toil-Free)
within Arkansas or locally and Out-of-State at (501) 376-2211.
Arkansas Medicaid provider manuals (including update
transmittals), official notices and remittance advice (RA) messages are
available for downloading from the Arkansas Medicaid website:
www.medicaid.state.ar.us.
Thank you for your participation in the Arkansas Medicaid
Program.
Roy Jeffus, Director
Rehabilitative Services for Persons with Physical
Disabilities
SECTION II
-REHABILITATIVE SERVICES FOR PERSONS WITH PHYSICAL DISABILITIES (RSPD)
CONTENTS
200.000
201.000
|
201.100 |
|
201.200 |
|
201.300 |
|
202.000 |
|
203.000 |
|
203.100 |
|
210.000 |
|
210.100 |
|
211.000 |
|
212.000 |
|
212.100 |
|
213.000 |
|
213.100 |
|
213.200 |
|
213.300 |
|
214.000 |
|
214.100 |
|
215.000 |
|
216.000 |
|
217.000 |
|
217.100 |
|
217.110 |
|
217.120 |
|
217.130 |
|
217.131 |
|
217.132 |
|
217.133 |
|
217.134 |
|
217.135 |
|
217.136 |
|
217.137 |
|
217.200 |
|
217.300 |
|
218.000 |
|
240.000 |
|
250.000 |
|
251.000 |
|
252.000 |
|
260.000 |
|
261.000 |
|
262.000 |
|
262.100 |
|
262.200 |
|
262.300 |
|
262.310 |
REHABILITATIVE SERVICES FOR PERSONS WITH PHYSICAL
DISABILITIES (RSPD) GENERAL INFORMATION
Arkansas Medicaid Participation Requirements for Providers of
Rehabilitative
Services for Persons with Physical Disabilities (RSPD)
Residential Rehabilitation Centers
Extended Rehabilitative Hospital
State-Operated Extended Rehabilitative Hospital
Out-of-State Providers
Records Requirement
Retention of Records
PROGRAM COVERAGE
Introduction
Scope
The Facility-Based Interdisciplinary Team
Responsibilities of the Facility-Based Interdisciplinary
Team
Admission Criteria
Medical Necessity
Medical Profile
Medical Diagnosis
Plan of Care
Periodic Review of Plan of Care
Covered Services
Exclusions
Benefit Limits
Coverage Limitation-Medicaid Utilization Management
Program
MUMP Applicability
MUMP Exemption
MUMP Procedures
Extension of RSPD Admissions
Transfer Admissions
Retroactive Medicaid Eligibility
Third Party and Medicare Claims
Post Payment Review
Administrative Reconsideration of Extension of Benefits
Denial
Appealing an Adverse Action
Facility Limitation
Services Limitation
Absent Days from the RSPD Facility
PRIOR AUTHORIZATION
REIMBURSEMENT
Method of Reimbursement for RSPD Services Rate Appeal
Process
BILLING PROCEDURES
Introduction to Billing
CMS-1450 (formerly UB-92) Billing Procedures
RSPD Procedure Code
Place of Service and Type of Service Codes
Billing Instructions-Paper Only
Completion of the CMS-1450 (formerly UB-92) Claim Form
Rehabilitative Services for Persons with Physical
Disabilities
262.400 Special
Billing Procedures
Rehabilitative Services for Persons with Physical
Disabilities
201.100
Residential Rehabilitation Centers
Residential rehabilitation centers must meet licensure,
accreditation and enrollment requirements to participate as RSPD providers in
the Arkansas Medicaid Program.
A. A
residential rehabilitation center must meet the following licensure
requirements:
1. Licensed by the Arkansas
Department of Health and Human Services, Office of Long Term Care, as a Post
Acute Head Injury Retraining and Residential Care Facility and
2. Licensed by the Arkansas Department of
Health and Human Services, Division of Children and Family Services, as a
Residential Child Care Facility
or
3. Licensed as a Long-Term Care Facility
that:
a. Provides transitional rehabilitation
of pediatric patients as defined in Ark. Code Ann §
20-8-101(7)
and
b. Operates a designated
section of the facility for pediatric patients whose anticipated stay at the
time of admission is six months or less.
B. A residential rehabilitation center must
meet one of the following accreditation requirements:
1. Accredited by the Commission on
Accreditation of Rehabilitation Facilities (CARF).
or
2. Accredited by the Joint Commission on
Accreditation of Healthcare Organization (JCAHO) as a Residential Treatment
Program for Post Acute Head Injury Rehabilitation.
C. A residential rehabilitation center must
meet the following provider enrollment requirements:
1. The residential rehabilitation center must
complete and submit to the Medicaid Provider Enrollment Unit a provider
application (form DMS-652), a Medicaid contract (form DMS-653) and a Request
for Taxpayer Identification Number and Certification (Form W-9) with the
Arkansas Medicaid Program. View or print a provider
application (form DMS-652), Medicaid contract (form DMS-653) and Request for
Taxpayer Identification Number and Certification (Form
W-9).
2. A
copy of the current licenses and accreditation must accompany the provider
application and the Medicaid contract.
3. 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.
4. Subsequent licenses and accreditation must
be forwarded to Provider Enrollment within 30 days of issuance. If the renewal
document(s) have not been received within this timeframe, the provider will
have an additional and final 30 days to comply.
5. Failure to timely submit verification of
license and accreditation renewal will result in termination of enrollment in
the Arkansas Medicaid Program.
201.200
Extended Rehabilitative
Hospital
The extended rehabilitative hospital must meet the following
participation requirements in order to be enrolled as an RSPD provider in the
Arkansas Medicaid Program:
A. The
extended rehabilitative hospital service provider must complete and submit to
the Medicaid Provider Enrollment Unit a provider application (form DMS-652), a
Medicaid
Rehabilitative Services for Persons with Physical
Disabilities
contract (form DMS-653) and a Request for Taxpayer
Identification Number and Certification (Form W-9) with the Arkansas Medicaid
Program. View or print a provider application (form DMS-652),
Medicaid contract (form DMS-653) and Request for Taxpayer Identification Number
and Certification (Form W-9).
B. The extended rehabilitative hospital must
be licensed by the Division of Health, Arkansas Department of Health and Human
Services, as a Rehabilitative Hospital. A copy of the current license must
accompany the provider application and the Medicaid contract. When a
beneficiary is dually eligible for Medicare and Medicaid, Medicare must be
billed prior to billing Medicaid. The beneficiary may not be billed for the
charges. Providers enrolled to participate in the Title XVIII (Medicare)
Program must notify the Arkansas Medicaid Program of their Medicare provider
number. Claims filed by Medicare "nonparticipating" providers do not
automatically cross over to Medicaid for payment of deductibles and
coinsurance.
A copy of subsequent license renewal must be provided when
issued.
C. The extended
rehabilitative hospital must be certified as a Title XVIII (Medicare)
Rehabilitative Hospital provider. A copy of the current certification must
accompany the provider application and the Medicaid contract.
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.
E. Renewal documents must be forwarded to the
Medicaid Provider Enrollment Unit within 30 days of issuance. If the renewal
document(s) have not been received within this timeframe, the provider will
have an additional, and final, 30 days to comply.
F. Failure to timely submit verification of
license and certification renewals will result in termination of enrollment in
the Arkansas Medicaid Program.
201.300
State-Operated Extended
Rehabilitative Hospital
The state-operated extended rehabilitative hospital must meet
the following participation requirements in order to be enrolled as an RSPD
provider in the Arkansas Medicaid Program:
A. The state-operated extended rehabilitative
hospital service provider must complete and submit to the Medicaid Provider
Enrollment Unit a provider application (form DMS-652), a Medicaid contract
(form DMS-653) and a Request for Taxpayer Identification Number and
Certification (Form W-9) with the Arkansas Medicaid Program.
View or print a provider application (form DMS-652), Medicaid
contract (form DMS-653) and Request for Taxpayer Identification Number and
Certification (Form W-9).
B. The state-operated extended rehabilitative
hospital must be licensed by the Division of Health, Arkansas Department of
Health and Human Services, as a Rehabilitative Hospital. A copy of the current
license must accompany the provider application and the Medicaid contract.
A copy of subsequent license renewal must be provided when
issued.
C. The
state-operated extended rehabilitative hospital must be certified as a Title
XVIII (Medicare) Rehabilitative Hospital provider. A copy of the current
certification must accompany the provider application and the Medicaid
contract. When a beneficiary is dually eligible for Medicare and Medicaid,
Medicare must be billed prior to billing Medicaid. The beneficiary may not be
billed for the charges. Providers enrolled to participate in the Title XVIII
(Medicare) Program must notify the Arkansas Medicaid Program of their Medicare
provider number. Claims filed by Medicare "non-participating" providers do not
automatically cross over to Medicaid for payment of deductibles and
coinsurance.
Rehabilitative Services for Persons with Physical
Disabilities
D. The
state-operated extended rehabilitative hospital must be operated by an Arkansas
state agency.
E. 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.
F. Renewal
documents must be forwarded to Provider Enrollment within 30 days of issuance.
If the renewal document(s) have not been received within this timeframe, the
provider will have an additional and final 30 days to comply.
G. Failure to timely submit verification of
license and certification renewals will result in termination of enrollment in
the Arkansas Medicaid Program.
210.000
PROGRAM COVERAGE
10-13-03
210.100
Introduction
The Medical Assistance Program (Medicaid) is designed to assist
eligible Medicaid beneficiaries in obtaining medical care within the guidelines
specified in Section I of this manual. All Medicaid benefits are based
upon medical necessity.
211.000
Scope
Rehabilitative Services for Persons with Physical Disabilities
(RSPD) services are provided for Medicaid-eligible beneficiaries when
prescribed by a licensed physician and deemed medically necessary by the
Quality Improvement Organization (QIO).
"Rehabilitative services" include medical or
remedial services recommended by a physician or other licensed practitioner of
the healing arts, within the scope of his or her practice under state law, for
maximum reduction of physical or mental disability and restoration of a
beneficiary to his or her best possible functional level. (Throughout this
manual, "physician" also includes "other licensed practitioners of the healing
arts.")
RSPD services require a medical referral from the beneficiary's
primary care physician (PCP), unless the beneficiary's is exempted from the PCP
requirements.
RSPD services covered under the Arkansas Medicaid Program must
be provided:
A. By a qualified RSPD
provider enrolled in the Arkansas Medicaid Program.
B. By an RSPD provider selected by the
beneficiary.
C. With certification
from the facility-based interdisciplinary team that the beneficiary meets the
criteria for RSPD services (see section 212.000).
D. As prescribed by a licensed
physician.
E. According to a
written plan of care.
F. By a
facility that is not part of a hospital. The facility must be organized and
operated to provide rehabilitative services to residential patients.
G. To an eligible Medicaid beneficiary who is
not an inpatient (see below) of a hospital, nursing facility (NF), intermediate
care facility for the mentally retarded (ICF/MR) or other institution.
"Inpatient" means a patient who has been
admitted to a medical institution on the recommendation of a physician or
dentist and is receiving room, board and professional services in the
institution on a continuous 24 hours a day basis or who is expected by the
institution to receive room, board and professional services for a 24 hour
period or longer.
Residential rehabilitation centers provide RSPD services only
to individuals who are under age 21 years. There is no age restriction for RSPD
services provided in extended rehabilitative hospitals and state-operated
extended rehabilitative hospitals.
When the admission criteria and the Medicaid Utilization
Management Program (MUMP) procedures have been met, the Medicaid Program will
cover RSPD services from the date of admission through the last day before the
Medicaid patient is discharged from the facility. The date of the discharge is
not covered by Medicaid.
212.000
The Facility-Based
Interdisciplinary Team
The RSPD provider must have a facility-based interdisciplinary
team consisting of the following medical personnel:
A. Neuropsychologist and/or physician,
licensed to practice in the State of Arkansas.
B. At a minimum, at least one of the
following must be employed or contracted by the facility to provide services to
Medicaid beneficiaries who are admitted to the facility:
1. Registered Nurse, licensed to practice in
the State of Arkansas, with at least one year's experience or specialized
training in the rehabilitation treatment setting.
2. Occupational Therapist, licensed to
practice in the State of Arkansas.
3. Physical Therapist, licensed to practice
in the State of Arkansas.
212.100
Responsibilities of the
Facility-Based Interdisciplinary Team
The responsibilities of the facility-based interdisciplinary
team include the following:
A.
Assessing the beneficiary's immediate and long range therapeutic
needs.
B. Assessing the
beneficiary's developmental priorities, personal strengths and
liabilities.
C. Assessing the
potential social resources of the beneficiary and the beneficiary's
family.
D. Developing the
beneficiary's plan of care.
E.
Setting treatment objectives.
F.
Prescribing therapeutic modalities to achieve the objectives of the individual
plan of care.
213.000
Admission Criteria
Medicaid beneficiaries are eligible for RSPD services for up to
four (4) days if they meet each of the following admission criteria:
A. Medical necessity (section
213.100)
B. Medical profile
(section 213.200)
C. Medical
diagnosis (section 213.300)
RSPD admissions are subject to reviews by the Quality
Improvement Organization (QIO). If the QIO or the Director of the Medicaid
Program later determines that an RSPD admission was not medically necessary,
Medicaid will not cover the RSPD services and the patient cannot be liable for
payment of the services.
(To certify a Medicaid beneficiary for RSPD services
beyond four [4] days, refer to section
217.100).
213.100
Medical Necessity
RSPD services are covered by Medicaid for eligible
beneficiaries when medically necessary. The medical
necessity criteria include:
A. A
prescription from a licensed physician stating that the Medicaid beneficiary
needs RSPD services. An individualized plan of care may serve as the
prescription for services. The prescription or plan of care must be signed and
dated by the physician.
B. The
physician must have examined the patient within the thirty (30) days preceding
the date of the written prescription or plan of care.
C. The prescription or plan of care will be
effective for up to three (3) months from the prescription date and must be
renewed before services may continue beyond three (3) months.
Persons needing rehabilitative services on a less intensive
basis than those provided in the inpatient setting may receive outpatient
rehabilitative services through other appropriate Medicaid services, e.g.,
outpatient hospital, physical therapy, occupational therapy, speech therapy,
rehabilitative services for persons with mental illness (RSPMI) and home
health.
213.200
Medical Profile
Medicaid beneficiaries must meet the following medical profile
prior to admission to an RSPD facility:
A. Ability to communicate through spoken,
written, gestural/environmental cues.
B. Absence of acute medical
problems.
C. Adequate nutrition
maintained without intravenous (IV) administration.
D. Does not require treatment for drug or
alcohol abuse, unless secondary to their injury.
E. Does not require a ventilator.
F. Free from any communicable disease that
would require total isolation.
G.
Mentally and physically able to participate in an intensive rehabilitation
program (minimum of 3 hours daily).
H. Motivated to live in the
community.
I. Must be medically
stable.
J. Must depend on others
for self-care, mobility or safety.
K. Requires at least two (2) rehabilitation
services, one of which must be a restorative therapy. (Refer to section
215.000.)
213.300
Medical Diagnosis
As part of the admission process to an RSPD facility, Medicaid
beneficiaries must meet the medical diagnosis criteria specified below.
A. Residential Rehabilitation Center
Persons eligible for admission to a residential rehabilitation
center must have at least one of the following neurological conditions:
Post acute traumatic or acquired brain injury. This includes
and is limited to viral encephalitis, meningitis, aneurysms, cerebral vascular
accident/stroke, post-operative tumors, anoxia, hypoxias, toxic
encephalopathies, refractory seizure disorders and congenital neurological
brain disorders. These conditions can be with or without moderate to severe
behavioral disorders secondary to a brain injury.
B. Extended Rehabilitative Hospital
Persons eligible for admission must have at least one of the
following neurological conditions:
Post acute traumatic or acquired brain injury. This includes
and is limited to viral encephalitis, meningitis, aneurysms, cerebral vascular
accident/stroke, post-operative tumors, anoxia, hypoxias, toxic
encephalopathies, refractory seizure disorders and congenital neurological
brain disorders. These conditions can be with or without moderate to severe
behavioral disorders secondary to a brain injury.
C. State-Operated Extended Rehabilitative
Hospital
Persons eligible for admission must have at least one of the
following neurological conditions:
1.
Post acute traumatic or acquired brain injury. This includes and is limited to
viral encephalitis, meningitis, aneurysms, cerebral vascular accident/stroke,
postoperative tumors, anoxia, hypoxias, toxic encephalopathies, refractory
seizure disorders and congenital neurological brain disorders. These conditions
can be with or without moderate to severe behavioral disorders secondary to a
brain injury.
2. Post acute
traumatic injuries or congenital disorders of the spinal cord.
215.000
Covered
Services
RSPD is a global service, covering all rehabilitative,
psychological and/or social services required of the admitting facility for
licensure, certification and/or accreditation. This includes evaluations,
therapies and visits by a licensed practitioner that are directly related to
the beneficiary's rehabilitative adjustment.
Licensed practitioners visiting the beneficiary for reasons
related to the beneficiary's rehabilitation treatment and/or the plan of care
might not bill Medicaid for the services separately. However, medical visits
and treatment not related to the beneficiary's rehabilitation and/or plan of
care might be billed separately by the practitioner, if the service is a
Medicaid covered service.
Specialty services are not included in the RSPD global service
coverage. Therefore, Medicaid-enrolled specialists, such as neurologists, who
see a beneficiary due to an injury may bill the Medicaid Program for any
Medicaid covered service rendered.
A provider who renders medical services (e.g., physician,
hospital, etc.) that are not included in the RSPD global service coverage must
be an Arkansas Medicaid provider and bill the Arkansas Medicaid Program before
they can be reimbursed.
The following services are included in the RSPD global
coverage:
A. Restorative Therapies -
Restorative therapies include physical, occupational, speech and cognitive
therapy. These therapies are provided in an individual or group
setting.
B. Behavioral
Rehabilitation - Behavioral rehabilitation includes diagnosis, evaluation and
treatment of aggression, depression, denial and other common behavioral
problems. Behavioral rehabilitation shall address the needs of individuals who
have experienced significant personality changes as a result of stroke, illness
or serious accident. These services help decrease and control disruptive
behaviors and improve coping skills.
C. Life Skills Training - Activities of daily
living that are rehabilitative in nature.
D. Individual and Group Counseling - These
services shall be provided for individuals who are suffering from
psychological/adjustment disorders, or substance abuse secondary to their
injury or illness. Family counseling may be included in this service when the
services are directed exclusively to the effective treatment of the beneficiary
and are included in the beneficiary's plan of care.
E. Assessment Services - These services
assess an individual's potential for functional improvement. Under the
direction of a neuropsychologist and/or physician, a team of specialists
provides an evaluation of the beneficiary. The team provides continuous testing
during the residential stay as determined medically necessary by the
neuropsychologist and/or physician.
F. Nursing Care - This service provides the
availability of registered nursing services 24 hours a day.
217.110
MUMP
Applicability
Medicaid beneficiaries are allowed up to four (4) days of RSPD
services as long as the admission criteria (refer to sections 213.000 through
213.300) are met. If a patient is not discharged before or during the fifth day
of the residential stay, AFMC must certify any additional days beyond
the initial four (4) days.
When a patient is transferred from one RSPD facility to
another, the stay must be certified by AFMC from the first day of transfer.
(See Transfer Admissions, section 217.132.)
217.120
MUMP Exemption
Individuals in all Medicaid eligibility categories and all age
groups, except beneficiaries under age 1, are subject to MUMP procedures.
Medicaid beneficiaries under age 1 at the time of admission are exempt from the
MUMP procedures for dates of service before their first birthday. (For MUMP
procedures on and after a child's first
birthday, see section 217.131, item D.)
217.131
Extension of RSPD
Admissions
A. When the RSPD provider's
neuropsychologist and/or physician determines that a patient (age 1 year or
older) should not be discharged by the fifth day of residential stay due to the
need for continued services, an RSPD medical staff member must contact AFMC and
request an extension of the RSPD admission. To request an extension, an RSPD
medical staff member must call AFMC.
View or print AFMC
contact information. The following information is required:
1. Patient's name and address (including ZIP
code).
2. Patient's date of
birth.
3. Patient's Medicaid ID
number.
4. Admission
date.
5. Name of the RSPD
provider.
6. RSPD Medicaid provider
number.
7. Principal diagnosis and
other diagnoses influencing this stay.
8. The number of days being requested for
continued residential stay.
9. All
available medical information justifying or supporting the necessity for
continued stay in the RSPD facility.
B. AFMC may be contacted at 1-800-426 -2234
between the hours of 8:30 a.m. and 12:00 noon and 1:00 and 5:00 p.m., Monday
through Friday, with the exception of holidays. View or print AFMC contact
information. All calls are limited to 10 minutes to allow equal access to all
providers and they will be monitored for quality assurance purposes.
C. Calls requesting an extension of the RSPD
admission may be made at any time during the stay (except in the case of a
transfer from another RSPD facility, refer to section 217.132). However, the
following will apply:
1. RSPD providers
initiating their request after the fourth day must accept the financial
liability should the stay not meet the medical criteria for continued RSPD
services.
2. If the provider delays
calling for an extension and the services are denied based on the lack of
medical necessity, the patient will not be held liable.
D. For a Medicaid patient under age 1, the
days from the admission date through the day before the patient's
first birthday are exempt from the MUMP procedures. MUMP procedures become
effective on the one-year birthday; the patient's birthday is the first day of
the four days not requiring MUMP certification. If the stay continues beyond
the fourth day following the patient's first birthday, the RSPD medical staff
must apply for MUMP certification to extend the RSPD admission.
E. AFMC utilizes Medicaid guidelines and the
medical judgment of its professional staff to determine the number of days to
extend the admission.
F. AFMC
assigns an authorization number to an approved extension request and sends
written notification to the RSPD facility.
G. Additional extensions may be requested if
more days are needed beyond AFMC's original extension.
H. If the extension request is denied by a
physician advisor with AFMC, the RSPD provider may request an expedited
reconsideration review by sending the medical record (through regular mail or
by overnight express) to AFMC for review and determination. The provider must
specify that an expedited reconsideration is being requested. The RSPD provider
will be notified of the decision by the next working day.
View or print the AFMC contact
information.
I.
Providers may request administrative reconsideration of an adverse decision or
they can appeal as provided in section 190.003 of this manual.
J. 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.
K. 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.
L. All parties
will be notified in writing of the outcome of the reconsideration.
M. Medicaid claims submitted without calling
AFMC for an extension request will result in automatic denials of any days
billed beyond the fourth day. The only exception is
claims involving third party liability. (See section 217.134.)
217.133
Retroactive Medicaid
Eligibility
A. If retroactive Medicaid
eligibility is determined prior to discharge of the patient, the RSPD provider
may call AFMC to request post-certification of the days beyond the first four
(4) days (or all days if the admission was by transfer) and a concurrent
extension for additional days, if needed.
B. If the retroactive Medicaid eligibility is
determined after discharge, the RSPD provider may call AFMC to request
post-certification of the days beyond the first four (4) days (or all days if
the admission was by transfer). If the certification is requested for a
length-of-stay longer than thirty (30) days, the provider must submit the
entire medical record to AFMC for review. (Refer to section 217.200 for the
annual benefit limit on the length-of-stays.) View or print
the AFMC contact information.
217.136
Administrative Reconsideration
of Extension 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.
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 will be considered on an
individual basis.
217.137
Appealing an Adverse Action
Please see section 190.003 for information
regarding administrative appeals.
217.200
Facility Limitation
The benefit limits will apply to each of the RSPD facilities as
specified below:
A. Residential
Rehabilitation Center
1. RSPD services
provided in a residential rehabilitation center are limited to
Medicaid-eligible beneficiaries who are under the age of 21 years.
2. Medicaid beneficiaries who are under the
age of 21 years and in the Child Health Services (EPSDT) Program are not
limited to a thirty (30) day annual benefit limit.
B. Extended Rehabilitative Hospital
1. RSPD services provided in an extended
rehabilitative hospital are not age limited.
2. RSPD services provided in an extended
rehabilitative hospital are limited to thirty (30) days per state fiscal year,
July 1 through June 30, for ages 21 and older. No extensions will be
considered. However, beneficiaries who are under the age of 21 years and
in the Child Health Services (EPSDT) Program are not limited to the thirty (30)
day annual benefit limit.
3. The
thirty (30) day annual benefit limit only applies to services provided in an
RSPD facility and does not include days counted toward any other Medicaid
Program benefit limit, e.g., hospital, nursing home, etc.
C. State-Operated Extended Rehabilitative
Hospital
1. RSPD services provided in a
state-operated extended rehabilitative hospital are not age limited.
2. RSPD services provided in a state-operated
extended rehabilitative hospital are limited to thirty (30) days per state
fiscal year, July 1 through June 30, for ages 21 and older. No extensions
will be considered. However, beneficiaries who are under the age of 21
years and in the Child Health Services (EPSDT) Program are not limited to the
thirty (30) day annual benefit limit.
3. The thirty (30) day annual benefit limit
only applies to services provided in an RSPD facility and does not include days
counted toward any other Medicaid Program benefit limit, e.g., hospital,
nursing home, etc.
217.300
Services Limitation
Because certain services would either result in a duplication
(i.e., the service is included in the RSPD global coverage) or would not be
appropriate for persons residing in an RSPD facility, services in the below
listed Medicaid Programs are not available to Medicaid beneficiaries who have
received RSPD services on the same date of service. These include:
A. Developmental Day Treatment Clinic
Services (DDTCS).
B. Developmental
Disabilities Services (DDS) Alternative Community Services (ACS) Waiver
Services.
C.
ElderChoices.
D. Home
Health.
E. Hospice.
F. Hyperalimentation (Parenteral
Nutrition).
G. Individual or Group
Psychological Therapy/Counseling or Testing. H. Inpatient Hospital (Acute
Care/General and/or Rehabilitative).
I. Inpatient Psychiatric Services for Under
Age 21.
J. Nursing Home.
K. Personal Care.
L. Occupational, Physical, or Speech Therapy,
including evaluations.
M. Private
Duty Nursing Services.
N.
Rehabilitative Services for Persons with Mental Illness (RSPMI).
O. Targeted Case Management.
P. Ventilator Equipment.
218.000
Absent Days from the RSPD
Facility 3-1-06
The Arkansas Medicaid Program will not cover the days the
beneficiary is absent from the facility, regardless of the reason for
absenteeism. When a beneficiary is absent from the
facility, the RSPD provider must document when the beneficiary left the
facility, if possible, why the beneficiary left, where the beneficiary was
going and, when applicable, the beneficiary's expected return date.
When a beneficiary is absent, the RSPD provider must follow one
of the following procedures:
A.
Formally discharge the beneficiary, regardless of the length of absenteeism.
I f the beneficiary is to be
readmitted, the RSPD provider must formally admit the beneficiary upon return
by following all normal admission policies as stated in this manual.
or
B. Allow the beneficiary up to seven (7) days
to return to the RSPD facility.
1.I f the beneficiary returns to
the RSPD facility within seven (7) days, the RSPD provider must conduct a plan
of care review within three (3) days of the beneficiary's return and modify the
plan of care as necessary.
2. If
the beneficiary does not return to the RSPD facility within seven (7) days, the
RSPD provider must formally discharge the beneficiary. If the beneficiary is to
be readmitted, the RSPD provider must formally admit the beneficiary by
following the normal procedures, as stated in this manual.
240.000 PRIOR AUTHORIZATION
Prior authorization does not apply to RSPD services. Extended
RSPD services after the initial four (4) days must follow the MUMP procedures
in sections
217.100 through
217.135.
