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016.06.20-210.100. Introduction

AR ADC 016.06.20-210.100Arkansas Administrative CodeEffective: November 1, 2023

West's Arkansas Administrative Code
Title 016. Department of Human Services
Division 06. Division of Medical Services
Rule 20. Hospital/Critical Access Hospital (CAH)/End-Stage Renal Disease (ESRD) Provider Manual (Refs & Annos)
Section 210.000. Program Coverage -- Hospital and Critical Access Hospital.
Effective: November 1, 2023
Ark. Admin. Code 016.06.20-210.100
016.06.20-210.100. Introduction
Currentness
The Medical Assistance (Medicaid) Program helps eligible individuals obtain necessary medical care.
A. Medicaid coverage is based on medical necessity.
1. See Section IV of this manual for the Medicaid Program's definition of medical necessity.
2. Some examples of services that are not medically necessary are treatments or procedures that are cosmetic or that the medical profession does not generally accept as a standard of care (e.g., an inpatient admission to treat a condition that requires only outpatient treatment).
B. Medicaid denies coverage of services that are not medically necessary. Denial for lack of medical necessity is done in several ways.
1. When Arkansas Medicaid's Division of Medical Services' Medical Director for Clinical Affairs determines that a service is never medically necessary, the Division of Medical Services (DMS) enters the service's procedure code, revenue code and/or diagnosis code into the Medicaid Management Information System (MMIS) as non-payable, which automatically prevents payment.
2. A number of services are covered only with the Program's prior approval or prior authorization. One of the reasons for requiring prior approval of payment or prior authorization for a service is that some services are not always medically necessary and Medicaid wants its own medical professionals to review the case record before making payment or before the service is provided.
3. Lastly, Medicaid retrospectively reviews medical records of services for which claims have been paid in order to verify that the medical record supports the service(s) for which Medicaid paid and to confirm or refute the medical necessity of the services documented in the record.
C. Unless a service's medical necessity or lack of medical necessity has been established by statute or regulation, medical necessity determinations are made by the Arkansas Medicaid Program's Medical Director, by the Program's Quality Improvement Organizations (QIO) and/or by other qualified professionals or entities authorized and designated by the Division of Medical Services.
D. When Arkansas Medicaid's Division of Medical Services' Medical Director for Clinical Affairs, QIO or other designee determines -- whether prospectively, concurrently or retrospectively -- that a hospital service is not medically necessary, Medicaid covers neither the hospital service nor any related physician services.

Credits

Eff. Oct. 1, 2008. Amended Nov. 1, 2023.
<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 016.06.20-210.100, AR ADC 016.06.20-210.100
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