A. Medicaid covers medically necessary hospital services, within the constraints of the Medicaid Utilization Management Program (MUMP) and applicable benefit limitations.
B. The care and treatment of a patient must be under the direction of a licensed physician or dentist with hospital staff affiliation. Most inpatient admissions require a PCP referral. (Refer to Section I of this manual.)
C. DHS or its designated vendor reviews all inpatient hospital transfers and all inpatient stays longer than four (4) days for the Medicaid Utilization Management Program.
DHS or its designated vendor also completes post-payment reviews of hospital stays of any length for medical necessity determinations. View or print DHS or designated vendor contact information to obtain MUMP information.
D. Hospital claims are also subject to review by the Division of Medical Services Medical Director for Clinical Affairs for the Medicaid Program.
1. If Medicaid denies a hospital's claim for lack of medical necessity, payments to practitioners for evaluation and management services incidental to the hospitalization are subject to recoupment by the Medicaid agency.
2. Practitioners and hospitals may not bill a Medicaid beneficiary for a service Medicaid has declared not medically necessary.
3. Practitioners and hospitals may not bill as outpatient services, inpatient services previously denied for lack of medical necessity.
4. Refer to Sections I and III of this manual for Medicare deductible and coinsurance information.
Credits
Eff. Nov. 1, 2008. Amended Aug. 1, 2021.
<Editor’s Note: Nonfunctioning links so in original.>
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 016.06.36-203.170, AR ADC 016.06.36-203.170
