Section IIPodiatrist
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.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 providerc.Include clinical, outpatient and/or emergency room records for dates of service in chronological orderd.Include related diabetic and blood pressure flow sheetse.Include current medication list for date of servicef.Include obstetrical record related to current pregnancyg.Include clinical indication for laboratory and x-ray services ordered with a copy of orders for laboratory and x-ray services signed by the physician2. Laboratory and radiology reports must include:a. Clinical indication for laboratory and x-ray services ordered b.Signed orders for laboratory and radiology servicesc.Results signed by performing providerd.Current and all previous ultrasound reports, including biophysical profiles and fetal non-stress tests215.115 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)3. Patient Medicaid identification number4. Podiatrist name and license number5. Podiatrist Medicaid provider number6. Hospital or ambulatory surgery center name7. Date of service for requested procedure8. Facility Medicaid provider number9. CPT code for procedure(s)10. Principal diagnosis and any other diagnoses11. Signs/symptoms of illness12. 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.