Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.05-098 - Visual Care Provider Manual Update Transmittal #66

Current through Register Vol. 49, No. 6, June, 2024
SECTION II -VISUAL CARE
200.000
VISUAL CARE GENERAL
			 INFORMATION
201.000
Arkansas Medicaid Participation Requirements for Visual Care Providers
Visual Care Program providers meeting the following criteria
				are eligible for participation in the Arkansas Medicaid Program:
A. Provider must be licensed by the State
			 Board of Optometry to practice in his or her state. A current copy of the
			 optometrist's license must be submitted with the provider application for
			 participation. Subsequent licensure must be provided when issued.
1. Subsequent license renewal must be
			 forwarded to Provider Enrollment within 30 days of issue. If the renewal
			 documents have not been received within the 30-day deadline, the provider will
			 have an additional and final 30 days to comply.
2. Failure to ensure that current licensure
			 is on file with Provider Enrollment will result in termination from the
			 Arkansas Medicaid Program.
B. Provider must be enrolled in the Title
			 XVIII (Medicare) Program.
C.
			 Provider must complete a provider application (Form DMS-652), a Medicaid
			 contract (Form DMS-653) and a Request for Taxpayer Identification Number and
			 Certification (Form W-9).
View or print the provider
			 application (Form DMS-652), the Medicaid contract (Form DMS-653) and the
			 Request for Taxpayer Identification Number and Certification (Form
			 W-9).
D.
			 Enrollment as a Medicaid provider is conditioned upon approval of a completed
			 provider application and the execution of a Medicaid provider contract. Persons
			 and entities that are excluded or debarred under any state or federal law,
			 regulation or rule are not eligible to enroll, or to remain enrolled, as
			 Medicaid providers.
Visual Care Providers in Arkansas and Bordering
				States
Visual Care Program providers in Arkansas and the bordering
				states of Louisiana, Mississippi, Missouri, Oklahoma, Tennessee and Texas will
				be enrolled as routine services providers.
Routine Services Providers
A. Provider will be enrolled in the program
			 as a regular provider of routine services.
B. Reimbursement will be available for all
			 visual care services covered in the Arkansas Medicaid Program.
C. Claims must be filed according to Section
			 240.000 of this manual. This
			 includes assignment of ICD-9-CM and HCPCS codes for all services rendered.
Visual Care Providers in Non-Bordering
				States
All Visual Care Program providers in non-bordering states may
				be enrolled only as limited services providers.
Limited Services Providers
A. Providers will be enrolled in the program
			 to provide prior authorized or emergency services only.
"Emergency services" are defined as inpatient or outpatient
				hospital services that a prudent layperson with an average knowledge of health
				and medicine would reasonably believe are necessary to prevent death or serious
				impairment of health and which, because of the danger to life or health,
				require use of the most accessible hospital available and equipped to furnish
				those services. Source: 42 U.S. Code of Federal Regulations §
											422.2 and §
											424.101.
"Prior authorized services" are those that are medically
				necessary and not available in Arkansas. Each request for these services must
				be made in writing, forwarded to the Utilization Review Section and approved
				before the service is provided. An Arkansas Medicaid Provider Contract must be
				signed before reimbursement can be made. A provider number will be assigned
				upon receipt and approval of the provider application and Medicaid contract.
View or print the Division of Medical Services, Utilization
				Review Section contact information
.
B. Limited Services provider claims will be
			 manually reviewed prior to processing to ensure that only emergency or prior
			 authorized services are approved for payment. These claims should be mailed to
			 the Arkansas Division of Medical Services, Program Communications Unit.
View or print the Division of Medical Services, Program
			 Communications Unit contact
			 information.
201.100
Group Providers of Visual Care
			 Services
Group providers of visual care services must meet the following
				criteria in order to be eligible for participation in the Arkansas Medicaid
				Program.
In situations where an optometrist is a member of a group, each
				individual optometrist and the group must both enroll according to the
				following criteria:
A. Each individual
			 optometrist in the group must enroll following the criteria established in
			 Section 201.000.
B. The group must complete a provider
			 application and Medicaid contract as an Arkansas Medicaid provider of visual
			 care services. See Section
			 I of this manual. Enrollment as a
			 Medicaid provider is conditioned upon approval of a completed provider
			 application and the execution of a Medicaid provider contract. Persons and
			 entities that are excluded or debarred under any state or federal law,
			 regulation or rule are not eligible to enroll, or to remain enrolled, as
			 Medicaid providers.
All group providers are "pay to" providers
only
. The service must be performed and billed by a
				licensed and enrolled optometrist with the group.
202.000 Visual Care Records Providers are
			 Required to Keep Visual care providers are required to keep the following
			 records and, upon request, must immediately furnish the records to authorized
			 representatives of the Division of Medical Services, the state Medicaid Fraud
			 Control Unit, representatives of the Department of Health and Human Services
			 and the Centers for Medicare and Medicaid Services:
A. History and visual care examination on
			 initial visit.
B. Chief complaint
			 on each visit.
C. Tests and
			 results.
D. Diagnosis.
E. Treatment, including
			 prescriptions.
F. Signature or
			 initials of visual care provider after each visit.
G. Copies of hospital and/or emergency room
			 records that are available to disclose services.
1. All records must be kept for five (5)
			 years from the ending date of service or until all audit questions, appeal
			 hearings, investigations or court cases are resolved, whichever is longer.
			 Failure to furnish these records upon request may result in sanctions being
			 imposed.
2. All documentation must
			 be immediately made available to representatives of the Division of Medical
			 Services at the time of an audit by the Medicaid Field Audit Unit. All
			 documentation must be available at the provider's place of business. When a
			 recoupment is necessary, no more than thirty (30) days will be allowed after
			 the date of the recoupment notice in which additional documentation will be
			 accepted. Additional documentation will not be accepted after the 30 days
			 allowed after recoupment.
3. Visual
			 Care providers furnishing any Medicaid-covered good or service for which a
			 prescription is required by law, by Medicaid rule, or both, must have a copy of
			 the prescription for such good or service. The Visual Care provider must obtain
			 a copy of the prescription within five (5) business days of the date the
			 prescription is written.
4. The
			 Visual Care provider must maintain a copy of each relevant prescription in the
			 Medicaid beneficiary's records and follow all prescriptions and care
			 plans.
5. The Visual Care provider
			 must adhere to all applicable professional standards of care and
			 conduct.
216.230
Administrative Reconsideration
			 of Extensions of Benefits Denial
A request for administrative reconsideration of an extension of
				benefits denial must be in writing and sent to AFMC within 30 calendar days of
				the denial. The request must include a copy of the denial letter and additional
				supporting documentation pursuant to section
				221.100.
The deadline for receipt of the reconsideration request will be
				enforced pursuant to sections
				190.012 and
				190.013 of this manual. A request
				received by AFMC within 35 calendar days of a denial will be deemed timely. A
				request received later than 35 calendar days gives rise to a rebuttable
				presumption that it is not timely.
216.240
Appealing an Adverse Action
Please see section
				190.000 et al for information
				regarding administrative appeals.
221.100
AFMC Extension of Benefits
			 Review Process
The following is a step-by-step outline of AFMC's extension of
				benefits review process:
A. Requests
			 received via mail are screened for completeness and researched to verify the
			 beneficiary's eligibility for Medicaid when the service was provided and to
			 determine whether the claim has already been paid.
B. The documentation submitted is reviewed by
			 a nurse. If, in the judgment of the nurse the documentation supports medical
			 necessity, he or she may approve the request. An approval letter is computer
			 generated and mailed to the provider the following day.
C. If the nurse reviewer determines the
			 documentation does not justify the service or it appears that the service is
			 not medically necessary, he or she will refer the case to the appropriate
			 physician advisor for a decision.
D. The physician reviewer's rationale for
			 approval or denial is entered into the computer review system and the
			 appropriate notification is created. If services are denied for medical
			 necessity, the physician reviewer's reason for the decision is included in the
			 denial letter. A denial letter is mailed to the provider and the beneficiary
			 the following work day.
E.
			 Providers may request administrative reconsideration of an adverse decision or
			 they can appeal as provided in section
			 190.003 of this manual.
F. If the denial is because of incomplete
			 documentation, but complete documentation that supports medical necessity is
			 submitted with the reconsideration request, the nurse may approve the extension
			 of benefits without referral to a physician advisor.
G. If the denial is because there is no proof
			 of medical necessity or the documentation does not allow for approval by the
			 nurse, the original documentation, reason for denial and new information
			 submitted will be referred to a different physician advisor for
			 reconsideration.
H. All parties
			 will be notified in writing of the outcome of the reconsideration.
222.000
Duration of
			 Authorization
Medical assistance prior authorizations are valid for 180 days
				from date of approval, provided the patient remains eligible for services.
				Prior authorization does not guarantee payment unless the patient remains
				eligible.
The doctor's office will be responsible for verifying
				eligibility for the dates in which servic
es are
provided. The patient is responsible for telling the doctor that
				he or she is a Medicaid beneficiary when making the first appointment.
The doctor should always keep a copy of the services authorized
				with the prior authorization control number and a copy of each claim submitted.
				If the treatment has not been completed in this period of time, send a new
				request for authorization for the portion of the plan not completed. A new
				prior authorization control number may be issued under prevailing
				policies.