Prior Authorization Procedures 

Medicaid requires that some surgical procedures be authorized by AFMC prior to the performance of the procedure. Procedures can require authorization regardless of whether they are performed on an inpatient or outpatient basis. To request authorization, call AFMC at 800-426-2234 between 8:30 a.m.-12 p.m. and 1 p.m.-5 p.m. Monday through Friday, with the exception of holidays. See "Procedure for Obtaining Prior Authorization from Arkansas Foundation for Medical Care (AFMC)" in the Arkansas Medicaid Provider Manual, Section 241.000, page II-68 through page II-73. 

CPT codes that require prior authorization by AFMC can be found in your Arkansas Medicaid Provider Manual. (Section 244.000, page II-70 through page II-71.) These manuals, as well as the manual updates, are disseminated to all Arkansas Medicaid providers by Medicaid.

The following information is required for AFMC to conduct a review for medical necessity of a prior-authorization procedure:

1. Patient name and address (including zip code)
2. Patient birthdate
3. Patient Medicaid number
4. Admission and procedure date
5. Hospital or ambulatory surgery center name
6. Facility Medicaid provider number
7. Medicaid provider number of physician performing procedure
8. CPT code for procedure(s)
9. Principal diagnosis and any other diagnoses
10. Signs/symptoms of illness
11. Medical indication for justification of procedure(s)

AFMC pre-certification number: 800-426-2234
AFMC phone review hours: 8:30 a.m.-12 p.m. and 1 p.m.-5 p.m. Monday through Friday, with the exception of holidays. All calls are monitored for quality assurance purposes.

Questions?

E-mail: Internal review manager/AFMC
mump_contact@afmc.org

Authorization for procedures, assistant surgeons or length of stays indicates that AFMC has determined medical necessity. It does not indicate that the patient is eligible for Medicaid coverage. The provider is responsible for verifying patient eligibility for the dates of service.