Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.05-101 - Rehabilitative Services for Persons with Physical Disabilities Provider Manual Update Transmittal #38

Current through Register Vol. 49, No. 6, June, 2024
Arkansas Medicaid Health Care Providers - Rehabilitative
				Services for Persons with Physical Disabilities Provider Manual Update
				Transmittal #38 Page 2
Section 219.000
			 has been deleted and replaced by section 217.137 which now discusses the
			 appeals process that was previously located in this section.
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
				absenteeis
m. Wh
en 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.