Current through Register Vol. 49, No. 9, September, 2024
Section II
Podiatrist
201.400
Podiatrists in States Not Bordering Arkansas
A. Podiatrists in states not bordering
Arkansas are called limited services providers because they may enroll in
Arkansas Medicaid only after they have treated an Arkansas Medicaid beneficiary
and have a claim to file, and because their enrollment automatically expires.
1. A non-bordering state provider may send a
claim to Provider Enrollment and Provider Enrollment will forward by return
mail a provider manual and a provider application and contract.
View or print Medicaid Provider Enrollment Unit contact
information.
2.
Alternatively, a non-bordering state provider may download the provider manual
and provider application materials from the Arkansas Medicaid website,
www.medicaid.state.ar.us, and then submit its application and claim to the
Medicaid Provider Enrollment Unit.
B. Limited services providers remain enrolled
for one year.
1. If a limited services
provider treats another Arkansas Medicaid beneficiary during its year of
enrollment and bills Medicaid, its enrollment may continue for one year past
the newer claim's last date of service, if the provider keeps the enrollment
file current.
2. During its
enrollment period the provider may file any subsequent claims directly to
EDS.
3. Limited services providers
are strongly encouraged to submit claims through the Arkansas Medicaid website
because the front-end processing of web-based claims ensures prompt
adjudication and facilitates reimbursement.
203.200
Documentation in Beneficiary
Files
The provider must contemporaneously create and maintain records
that completely and accurately explain all evaluations, care, diagnoses and any
other activities of the provider in connection with its delivery of medical
assistance to any Medicaid beneficiary.
Providers furnishing any Medicaid-covered good or service for
which a prescription, admission order, physician's order, care plan or other
order for service initiation, authorization or continuation is required by law,
by Medicaid rule, or both, must obtain a copy of the aforementioned
prescription, care plan or order within five (5) business days of the date it
is written. Providers also must maintain a copy of each prescription, care plan
or order in the beneficiary's medical record and follow all prescriptions, care
plans, and orders as required by law, by Medicaid rule, or both.
The provider must adhere to all applicable professional
standards of care and conduct.
Documentation should consist of, at a minimum, material that
includes:
A. History and physical
examination.
B. Chief complaint on
each visit.
C. Tests and
results.
D. Diagnosis.
E. Treatment including
prescriptions.
F. Signature or
initials of podiatrist after each visit.
G. Copies of office, clinic, hospital and/or
emergency room records that are available to disclose services.
H. Each record must reflect date of visit
when services were provided.
203.300
Record Keeping Requirements
All records must be completed promptly, filed and retained for
a minimum of five (5) years from the date of service or until all audit
questions, appeal hearings, investigations or court cases are resolved,
whichever is longer.
The provider must make available to the Division of Medical
Services, its contractors and designees and the Medicaid Fraud Control Unit,
all records related to any Medicaid beneficiary. All documentation must be
available at the provider's place of business during normal business hours.
When records are stored off-premise or are in active use, the provider may
certify, in writing, that the records in question are in active use or in
off-premise storage and set a date and hour within three (3) working days, at
which time the records will be made available. However, the provider will not
be allowed to delay for matters of convenience, including availability of
personnel.
At the time of an audit by the Division of Medical Services,
Field Audit Unit, all documentation must be made available for review as
outlined in the previous paragraph. In the case of recoupment, there will be no
more than thirty days allowed after the date of the recoupment notice in which
additional documentation will be accepted. Additional documentation will not be
accepted after the thirty-day period.
Failure to furnish records upon request may
result in sanctions being imposed.
215.100
Procedure for Obtaining
Extension of Benefits for Podiatry Services
A. Requests for extension of benefits for
podiatry services for beneficiaries under age 21 must be mailed to the Arkansas
Foundation for Medical Care, Inc. (AFMC).
View or print the
Arkansas Foundation for Medical Care, Inc., contact information.
A request for extension of benefits must meet the medical necessity
requirement, and adequate documentation must be provided to support this
request.
1. Requests for extension of
benefits are considered only after a claim is denied because a benefit is
exhausted.
2. The request for
extension of benefits must be received by AFMC within 90 calendar days of the
date of the benefits-exhausted denial. The count begins on the next working day
after the date of the Remittance and Status Report (RA) on which the
benefits-exhausted denial appears.
3. Submit with the request a copy of the
Medical Assistance Remittance and Status Report reflecting the claim's denial
for exhausted benefits. Do not send a claim.
4. AFMC will not accept extension of benefits
requests sent via electronic facsimile (FAX).
B. Use form DMS-671, Request for Extension of
Benefits for Clinical, Outpatient, Laboratory and X-Ray Services, to request
extension of benefits for podiatry services. View or print
form DMS-671.
Consideration of requests for extension of
benefits requires correct completion of all fields on this form. The
instructions for completion of this form are located on the back of the form.
The provider's signature (with his or her credentials) and the date of the
request are required on the form. Stamped or electronic signatures are
accepted. All applicable records that support the medical necessity of the
extended benefits request should be attached.
C. AFMC will approve or deny an extension of
benefits request - or ask for additional information - within 30 calendar days
of their receiving the request. AFMC reviewers will simultaneously advise the
provider and the beneficiary when a request is denied.
215.110
Documentation Requirements
A. To request extension of benefits
for any benefit limited service, all applicable records that support the
medical necessity of extended benefits are required.
B. Documentation requirements are as follows.
1. Clinical records must:
a. Be legible and include records supporting
the specific request
b.Be signed by the
performing provider
c.Include
clinical, outpatient and/or emergency room records for dates of service in
chronological order
d.Include
related diabetic and blood pressure flow sheets
e.Include current medication list for date of
service
f.Include obstetrical
record related to current pregnancy
g.Include clinical indication for laboratory
and x-ray services ordered with a copy of orders for laboratory and x-ray
services signed by the physician
2. Laboratory and radiology reports must
include:
a. Clinical indication for laboratory
and x-ray services ordered
b.Signed
orders for laboratory and radiology services
c.Results signed by performing
provider
d.Current and all previous
ultrasound reports, including biophysical profiles and fetal non-stress
tests
215.115
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.
215.120
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 35 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. Reconsideration requests must be mailed and will not be
accepted via facsimile or email.
215.130
Appealing an Adverse Action
Please see section 190.003 for information regarding
administrative appeals.
221.100
Procedure for Requesting Prior
Authorization
It is the responsibility of the podiatrist to initiate the
prior authorization request. The podiatrist or his or
her office nurse must contact AFMC to request prior authorization.
View or print AFMC contact information.
To request authorization, call AFMC at 1-800-426 -2234, between the
hours of 8:30 a.m.-12:00 noon and 1:00 p.m.-5:00 p.m., Monday through Friday,
with the exception of holidays.
CPT codes that require prior authorization by AFMC are located
in section
242.120 of this manual.
A. When calling AFMC to perform a review for
medical necessity of a prior authorization procedure, the following information
will be required: (All calls will be tape-recorded for quality assurance
purposes.)
1. Patient name and address
(including ZIP code)
2. Patient
birth date
3. Patient Medicaid
identification number
4. Podiatrist
name and license number
5.
Podiatrist Medicaid provider number
6. Hospital or ambulatory surgery center
name
7. Date of service for
requested procedure
8. Facility
Medicaid provider number
9. CPT
code for procedure(s)
10. Principal
diagnosis and any other diagnoses
11. Signs/symptoms of illness
12. Medical indication for justification of
procedure(s)
B. All
patient identification information and medical information related to the
necessity of the procedure must be provided for services to be
authorized.
