Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.05-097 - Occupational, Physical and Speech Therapy Services Update Transmittal #55

Current through Register Vol. 49, No. 6, June, 2024
Section II
			 Occupational, Physical, Speech Therapy Services
214.210
Retrospective Therapy Review
			 Process
Retrospective therapy review encompasses occupational therapy
				(OT), speech language pathology (SLP) and physical therapy (PT) services that
				provide evaluation and treatment for the purpose of improving function and
				preventing long-term disabilities in Medicaid-eligible beneficiaries underage
				twenty-one (21). The primary care physician (PCP) or attending physician is
				responsible for referring the beneficiary for these interventions. Therapeutic
				intervention is covered in public schools and therapy clinics. A valid
				prescription written and signed by the PCP or attending physician on the
				revised DMS-640 form is required. This prescription is valid for the length of
				time indicated by the physician or up to one (1) year from the date of the
				physician's signature.
On a calendar quarterly basis, Arkansas Foundation for Medical
				Care, Inc. (AFMC) will select and review a percentage random sample of all the
				therapy services billed and paid during the past three months (previous
				quarter). The written request for record copies is mailed to each provider
				along with instructions for mailing of the records. The request asks for the
				child's parent/guardian name and address and lists the child's name, date of
				birth, Medicaid identification number, dates of services, type of therapy, date
				of request and a listing of the documentation required for review. The
				provider(s) must copy and mail the information to AFMC within 30 calendar days
				of the request date printed in the record request cover letter. If the
				requested information is not received within the 30 day timeframe, a medical
				necessity denial is issued.
Post payment review of therapies is a dual process: The
				utilization review determines whether billed services were prescribed and
				delivered as billed, and the medical necessity review determines whether the
				amount, duration and frequency of services provided were medically
				necessary.
Providers must send the requested record copies via mail to
				AFMC. When the records are received, each record is stamped with the receipt
				date and entered into the computer review and tracking system. This system
				automatically generates a notification to the provider that a record(s) has
				been received. The Receipt of Requested Therapy Records letter is an
				acknowledgement of receipt of the record(s) only. Individual records have not
				been assessed for completeness of documentation. Additional documentation may
				be requested from the provider at a later date in order to complete a
				retrospective therapy review audit.
Records will not be accepted via facsimile or email.
214.220
Medical Necessity
			 Review
The record is initially reviewed by a registered nurse using
				screening guidelines developed from the promulgated Medicaid therapy manual.
				The nurse reviewer screens the chart to determine whether the correct
				information was submitted for review. If it is determined that the requested
				information was submitted correctly, the nurse reviewer can then review the
				documentation in more detail to determine whether it meets Medicaid eligibility
				criteria for medical necessity. The medical necessity review includes verifying
				that all therapy services have been provided under a valid PCP prescription
				(form DMS-640). A prescription is considered valid if it contains the following
				information: the child's name, Medicaid ID number, a valid diagnosis that
				clearly establishes and supports that the prescribed therapy is medically
				necessary, minutes and duration of therapy and is signed and dated by the PCP
				or attending physician. All therapy prescriptions must be on the revised
				DMS-640 form. Rubber-stamped signatures, those signed by the physician's nurse
				or a nurse practitioner and those without a signature date are not considered
				valid. Changes made to the prescription that alter the type and quantity of
				services prescribed are invalid unless changes are initialed and dated by the
				physician.
If the guidelines are met and medical necessity is approved,
				the nurse reviewer proceeds to the utilization portion of the review. If
				guidelines are not met or the prescription is invalid, the nurse reviewer
				refers the record to an appropriate therapist adviser for further
				review.
The therapist adviser may determine there is medical necessity
				even though the guidelines are not met, or make recommendation to the Associate
				Medical Director (AMD) for possible denial of all or part of the services
				provided. The AMD will review the recommendation and make a final decision to
				approve or deny. If the services are partially or completely denied, the
				provider, the beneficiary and the ordering physician are notified in writing of
				the denial. Each denial letter contains a rationale for the denial that is case
				specific. Each party is provided information about requesting reconsideration
				review or a fair hearing.
214.230
Utilization Review
When the billed services are determined to be medically
				necessary, the nurse reviewer proceeds to the utilization portion of the
				review. The computer review system lists all claims for services paid during
				the previous quarter for each beneficiary selected. This listing includes the
				procedure code and modifier, if required, dates of service billed and units
				paid. The nurse reviewer compares the paid claims data to the progress notes
				submitted. The previously mentioned screening guidelines are utilized to verify
				that the proper procedure code and modifier, if required, were billed, time
				in/out is documented, a specific description of the therapy services provided,
				activities rendered during the therapy session and some form of measurement is
				documented for each daily therapy session along with the providing therapist's
				signature (full name and credentials). If the documentation submitted supports
				the billed services, the nurse reviewer approves the utilization portion of the
				retrospective review. When documentation submitted does not support the billed
				services, the nurse reviewer refers the services not supported by documentation
				to an appropriate therapist for further review.
The therapist reviews the documentation and either approves the
				services as billed or provides a recommendation to the AMD to deny some or all
				of the services. If the AMD agrees with the denial, a denial letter is mailed
				to the provider, the ordering physician and the beneficiary. The letter
				includes case specific rationale explaining why the services did not meet
				established criteria.
214.240
Denial/Due Process
Retrospective Therapy Reviews may result in either a medical
				necessity or a utilization denial. For utilization only denials, the service
				provider is notified in writing of the denied services. The denial notification
				provides case specific rationale for the denial and will include instructions
				for requesting reconsideration. If the denial is for medical necessity, the PCP
				or attending physician and the services provider(s) will be notified in writing
				of the medical necessity denial. Each denial letter contains case specific
				denial rationale. The PCP denial letter informs the physician that a denial for
				therapy services on a specific Medicaid beneficiary has been issued. It states
				that he is being notified for information only because he might be called upon
				by the providers(s) to assist in the request for reconsideration. For either
				denial type, the provider is allowed 35 calendar days to submit additional
				information for reconsideration. Reconsideration review will not be performed
				if the additional information does not contain substantially different
				information than that previously submitted. Only one reconsideration is allowed
				per denial.
The beneficiary is notified in writing of all medical necessity
				denials at the same time the provider is notified. The beneficiary's denial
				letter includes case specific denial rationale and includes instructions for
				requesting a fair hearing. The beneficiary is not notified of utilization
				denials.
214.250
Reconsideration Review
See section
				216.315 for the deadline
				requirements to request an administrative reconsideration. If the request is
				received timely, the appropriate therapist reviews the additional information
				and determines if the services can be approved. If approved, the therapist
				reverses the previous denial. If the additional information submitted for
				reconsideration does not support medical necessity or the paid claims
				(utilization), the case is referred to a physician adviser for final
				determination. The therapist provides a written recommendation to the physician
				adviser.
The physician adviser may approve or deny all or part of the
				services. A written notification of the outcome of the reconsideration review
				is mailed to all parties. This notification includes a case specific rationale
				for upholding or overturning the denial.
All denial letters are available for inspection and approval by
				the Division of Medical Services (DMS).
214.260
Complaints
The Project Manager will respond in writing to DMS concerning
				complaints that are a direct result of an AFMC review determination. DMS may
				use the information provided by AFMC as needed.
216.300
Procedures for Obtaining
			 Extension of Benefits for Therapy Services
A. Requests for extension of benefits for
			 therapy 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.
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. Form DMS-671, Request for Extension of
			 Benefits for Clinical, Outpatient, Laboratory, and X-Ray Services, must be
			 utilized for requests for extension of benefits for therapy 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.
216.305 Documentation Requirements
A. To request an 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.
			 Clinical records must:
1. Be legible and
			 include records supporting the specific request
2. Be signed by the performing
			 provider
3. Include the physician
			 referral and prescription for additional therapy based on clinical records and
			 progress reports furnished by the performing provider
216.310
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 determine the
			 beneficiary's eligibility for Medicaid when the service was provided and to
			 determine if 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 the
			 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 adviser 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 adviser.
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 the denial and new information
			 submitted will be referred to a different physician adviser for
			 reconsideration.
H. All parties
			 will be notified in writing of the outcome of the reconsideration.
216.315
Administrative
			 Reconsideration
A request for administrative reconsideration of the denial of
				services 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.
216.320
Appealing an Adverse Action
Please see section
				190.003 for information regarding
				administrative appeals.
262.400
Special Billing Procedures
Services may be billed according to the care provided and to
				the extent each procedure is provided. Occupational, physical and speech
				therapy services do not require prior authorization.
Extension of benefits may be provided for all medically
				necessary therapy services for beneficiaries underage 21. Refer to sections
				216.000 through
				216.310 of this manual for more
				information.