PCP Packet. On the web: WHAT S NEW. >>> Timely Filing Notice <<< Arkansas Health Care Payment Improvement Initiative (AHCPII)

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1 PCP Packet FOR MORE INFORMATION, CONTACT: Tonyia Haynes, Supervisor, Outreach Logistics On the web: AFMC Provider Relations afmc.org/pcpupdatepackets Outreach Specialists Contact Information 2ND QUARTER, SFY OCT. 1,2016 DEC. 31, 2016 Click below to view any of the materials in this quarter s packets. Note: Some links will open a webpage. WHAT S NEW >>> Timely Filing Notice <<< Flu Update flu-season htm 2017 ICD-10 Billing Update Beneficiary Aid Categories Cough and Cold Drug List pharm/candclist.pdf LARC Project Arkansas Health Care Payment Improvement Initiative (AHCPII) paymentinitiative.org Patient Centered Medical Home (PCMH) n PCMH 24/7 Best Practices n PCMH FAQs paymentinitiative.org/medicalhomes/pages/faqs.aspx PCMH Deadlines What s Due? 2016 activity requirements (12-month activity) 2017 enrollment/pooling requirements PCMH Policy/Contacts Research, Reconsideration and Appeals Recovery of PBPM PCMH Contacts Prior Authorizations Quick Reference Guide for Medicaid Eligibility Quick%20Reference%20Medicaid%20Chart.pdf Update on Removal of 24-Day Hospital Cap n PCMH manual and program policy addendum paymentinitiative.org/medicalhomes/pages/useful-links.aspx n PCMH QA afmc.org/qa n PCMH Recovery of Practice Support n PCMH Research, Reconsideration and Appeals n Practice Transformation Arkansas Foundation for Medical Care (AFMC) CONTINUED, NEXT PAGE

2 PCP Packet FOR MORE INFORMATION, CONTACT: Tonyia Haynes, Supervisor, Outreach Logistics On the web: AFMC Provider Relations afmc.org/pcpupdatepackets Outreach Specialists Contact Information 2ND QUARTER, SFY OCT. 1,2016 DEC. 31, 2016 Click below to view any of the materials in this quarter s packets. Note: Some links will open a webpage. Episodes of Care (Algorithms) and Update Performance Period and Final Report Dates Links n Beneficiary Education afmc.org/arbeneed n Drug Lists Generic drug upper limit list Over the counter (OTC) drug list Preferred drug list (PDL) n Emergency Room ER Flow Sheets ER Trend Reports n Extension of Benefits (EOB) afmc.org/review/extension-of-benefits/ iexchange n EPSDT Billing sheet Fee schedule n Going Paperless Provider Address Change Form Foster care guidelines Screenings and sick visits Messages for remittance advice n Learn on Demand LODFlier2015.pdf n Medicaid Retroactive Eligibility n Outreach Update Newsletters afmc.org/outreachupdate n Patient Termination: PCP Transfers by PCP Request Deceased Patient Removal Process n PCP Assignment Required for Aid Category 06 n Quality Improvement Project Updates Alcohol use disorder Breastfeeding CT imaging in the emergency department Diabetes Opioids Pap smear/cervical cancer screening n Referral Policy n Third Party Liability Form (DCO-662 TPL) Update Call for assistance with adding or deleting insurance from a Medicaid beneficiary. n Voice Response System n What s New for Providers THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) UNDER CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. MP2-PCP.CD.10/16

3 Provider Relations Outreach Specialists Information Sheet 1020 W. 4th St., Suite 300 Little Rock, AR Toll free: Transportation Helpline: AFMC OUTREACH SPECIALISTS Refer to the map and the color key below to find your representative. Manager Sheryl Hurt [C] Supervisor, Outreach Logistics Tonyia Haynes Outreach Specialists Emily Alexander Becky Andrews Shawna Branscum Kellie Cornelius Carla Hestir Tabitha Kinggard Connie Riley Arkansas Children s Hospital Representative criley@afmc.org BENTON WASHINGTON FRANKLIN CRAWFORD SEBASTIAN POLK LITTLE RIVER SCOTT CARROLL MADISON LOGAN JOHNSON MONTGOMERY PIKE SEVIER HOWARD BOONE CLARK HEMPSTEAD NEVADA MILLER LAFAYETTE YELL NEWTON POPE GARLAND COLUMBIA PERRY HOT SPRING MARION SEARCY BAXTER VAN BUREN CONWAY FAULKNER PULASKI SALINE DALLAS GRANT OUACHITA CALHOUN UNION HP ENTERPRISE SERVICES PROVIDER RELATIONS (Claims Processing) 500 President Clinton Avenue, Suite 400 Little Rock, AR Operator Helpline In state toll free Local / out of state Voice Response System STONE CLEBURNE CLEVELAND BRADLEY FULTON IZARD LONOKE JEFFERSON INDEPENDENCE WHITE LINCOLN DREW ASHLEY SHARP PRAIRIE JACKSON ARKANSAS LAWRENCE WOODRUFF MONROE DESHA CHICOT RANDOLPH CLAY CRAIGHEAD CROSS LEE PHILLIPS GREENE POINSETT ST. FRANCIS 10/13/16 CRITTENDEN MISSISSIPPI Supervisor, Service Relations Karyette Simmons Manager, Provider Relations David Jarnagin ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES ARKIDS FIRST/ MEDICAID MEDICAL ASSISTANCE ARKids First Enrollment Information CONNECTCARE Toll free MEDICAID FRAUD CONTROL UNIT (PROVIDERS) Central Arkansas PROVIDER ENROLLMENT HP Enterprise Services, P.O. Box 8105 Little Rock, AR Central Arkansas Fax ARKANSAS MEDICAL SOCIETY REPRESENTATIVE PHYSICIAN OUTREACH SPECIALIST Gloria Boone gboone@arkmed.org

4 2017 ICD-10 CM and PCS codes Added 9/28/16 New, revised, and deleted 2017 ICD-10 CM and PCS codes are not yet updated in the Arkansas Medicaid claims processing system. This update is anticipated by November 4, 2016, retroactive to dates of service on and after October 1, Please hold any claims that would require a new or revised 2017 ICD-10 CM and PCS code, and be aware of any ICD-10 CM and PCS code being deleted in the 2017 ICD-10 code set that would impact billing.

5 Beneficiary Aid Categories The following is the full list of beneficiary aid categories. Some categories provide a full range of benefits while others may offer limited benefits or may require cost sharing by a beneficiary. The following codes describe each level of coverage. FR LB AC MNLB MP/MF full range limited benefits additional cost sharing medically needy limited benefits market place/medically frail Category Description Code 01 ARKIDS B ARKids CHIP Separate Child Health Program LB, AC 06 New Adult Group MP/MF 09 SSI Program of All-Inclusive Care for the Elderly (PACE) FR 10 N WD NewCo Working Disabled New Cost Sharing (N) FR, AC 10 R WD RegCo Working Disabled Regular Medicaid Cost Sharing I FR, AC 11 AABD AABD FR 13 SSI SSI FR 14 SSI SSI FR 15 Program of All-Inclusive Care for the Elderly (PACE) FR 16 AA-EC AA-EC MNLB 17 AA-SD Aid to the Aged Medically Needy Spend Down MNLB 18 QMB-AA Aid to the Aged-Qualified Medicare Beneficiary (QMB) LB 18 S AR Seniors ARSeniors FR 20 AFDC-GRANT Parent Caretaker Relative FR 25 TM Transitional Medicaid FR 26 AFDC-EC AFDC Medically Needy Exceptional Category MNLB 27 AFDC-SD AFDC Medically Needy Spend Down MNLB 31 AAAB Aid to the Blind FR 33 SSI SSI Blind Individual FR 34 SSI SSI Blind Spouse FR 35 SSI SSI Blind Child FR 36 AB-EC Aid to the Blind-Medically Needy Exceptional Category MNLB 37 AB-SD Aid to the Blind-Medically Needy Spend Down MNLB 38 QMB-AB Aid to the Blind-Qualified Medicare Beneficiary (QMB) LB

6 Category Description Code 41 AABD Aid to the Disabled FR 43 SSI SSI Disabled Individual FR 44 SSI SSI Disabled Spouse FR 45 SSI SSI Disabled Child FR 46 AD-EC Aid to the Disabled-Medically Needy Exceptional Category MNLB 47 AD-SD Aid to the Disabled-Medically Needy Spend Down MNLB 48 QMB- AD Aid to the Disabled-Qualified Medicare Beneficiary (QMB) LB 49 TEFRA TEFRA Waiver for Disabled Child AC 51 U-18 Under Age 18 No Grant FR 52 ARKIDS A Newborn FR 56 U-18 EC Under Age 18 Medically Needy Exceptional Category MNLB 57 U-18 SD Under Age 18 Medically Needy Spend Down MNLB 58 QI-1 Qualifying Individual-1 (Medicaid pays only the Medicare premium.) 61 PW-PL Women s Health Waiver - Pregnant Women, Infants & Children Poverty Level (SOBRA). A 100 series suffix (the last 3 digits of the ID number) is a pregnant woman; a 200 series suffix is an ARKids-First-A child. LB LB (for the pregnant woman only) FR (for SOBRA children) 61 PW Unborn Child Pregnant Women PW Unborn CH-no Ster cov Does not cover sterilization or any other family planning services. LB (for the pregnant woman only) 63 ARKIDS A SOBRA Newborn FR 65 PW-NG Pregnant Women No Grant FR 66 PW-EC Pregnant Women Medically Needy Exceptional Category MNLB 67 PW-SD Pregnant Women Medically Needy Spend Down MNLB 76 UP-EC Unemployed Parent Medically Needy Exceptional Category MNLB 77 UP-SD Unemployed Parent Medically Needy Spend Down MNLB 80 RRP-GR Refugee Resettlement Grant FR 81 RRP-NG Refugee Resettlement No Grant FR 86 RRP-EC Refugee Resettlement Medically Needy Exceptional Category MNLB 87 RRP-SD Refugee Resettlement Medically Needy Spend Down MNLB

7 Category Description Code 88 SLI-QMB Specified Low Income Qualified Medicare Beneficiary (SMB) (Medicaid pays only the Medicare premium.) 91 FC Foster Care FR 92 IVE-FC IV-E Foster Care FR 93 Former Foster Care FR 96 FC-EC Foster Care Medically Needy Exceptional Category MNLB 97 FC-SD Foster Care Medically Needy Spend Down MNLB LB Beneficiary Aid Categories with Limited Benefits Most Medicaid categories provide the full range of Medicaid services as specified in the Arkansas Medicaid State Plan. However, certain categories offer a limited benefit package. These categories are discussed below ARKids First-B Act 407 of 1997 established the ARKids First Program. The ARKids First-B Program incorporates uninsured children into the health care system. ARKids First-B benefits are comparable to the Arkansas state employees and teachers insurance program. Refer to the ARKids First-B provider manual for the scope of each service covered under the ARKids First-B Program Medically Needy The medically needy categories help provide medical care for those individuals who are medically eligible for benefits, but while their income and/or resources exceed the Medicaid limits for other types of assistance, the income is insufficient to pay for all or part of necessary medical care. Medically needy beneficiaries are covered for the full range of Medicaid benefits with the exception of long term care services (which includes ICF/IID) and personal care services. For more information regarding the medically needy program, providers may access the Medicaid website at Pregnant Women, Infants & Children The infants and children in the SOBRA (Sixth Omnibus Budget Reconciliation Act of 1986) aid category receive the full range of Medicaid benefits; however, the SOBRA pregnant women (PW-PL) receive only services related to the pregnancy and services that if not provided to PW-PLs could complicate the pregnancy. There are two groups of pregnant women, PW-PL and PW-Unborn CH. Both groups receive the same services during pregnancy. Generally, beneficiaries who are eligible for PW-PL are covered for postpartum follow-up services and family planning services. It is important to note that their PW-PL eligibility ends on the last day of the month in which the 60 th postpartum day occurs. PW-Unborn Child group (covered through the State Child Health Insurance program, which is authorized by Section 4901 of the Balanced Budget Act of 1997) does not cover sterilization or any other family planning services. Therefore, providers must verify eligibility to determine if the pregnant women is PW-PL or PW Unborn

8 Child (when providers check eligibility, the system will reflect: PW Unborn CH-no Ster cov for the Unborn Child group). A pregnant woman whose unborn child will be a US citizen (PW-Unborn Child) receives the same pregnancy services as those in the PW-PL category; however, after delivery, no family planning services (including sterilization) are covered Reserved Qualified Medicare Beneficiaries (QMB) The Qualified Medicare Beneficiary (QMB) group was created by the Medicare Catastrophic Coverage Act and uses Medicaid funds to assist low-income Medicare beneficiaries. QMBs do not receive the full range of Medicaid benefits. For example, QMBs do not receive prescription drug benefits from Medicaid or drugs not covered under Medicare Part D. If a person is eligible for QMB, Medicaid pays the Medicare Part B premium, the Medicare Part B deductible and the Medicare Part B coinsurance, less any Medicaid cost sharing, for Medicare covered medical services. Medicaid also pays the Medicare Part A hospital deductible and the Medicare Part A coinsurance, less any Medicaid cost sharing. Medicaid pays the Medicare Part A premium for QMBs whose employment history is insufficient for Title XVIII to pay it. Certain QMBs may be eligible for other limited Medicaid services. Only individuals considered to be Medicare/Medicaid dually eligible qualify for coverage of Medicaid services that Medicare does not cover. To be eligible for QMB, individuals must be age 65 or older, blind or an individual with a disability and enrolled in Medicare Part A or conditionally eligible for Medicare Part A. Their countable income may equal but may not exceed 100% of the Federal Poverty Level (FPL). Countable resources may be equal to but not exceed twice the current Supplemental Security Income (SSI) resource limitations. Generally, individuals may not be certified in a QMB category and in another Medicaid category simultaneously. However, some QMBs may simultaneously receive assistance in the medically needy categories, SOBRA pregnant women (61 and 62). QMB generally do not have Medicaid coverage for any service that is not covered under Medicare; with the exception of the above listed categories and individuals dually eligible. Individuals eligible for QMB receive a plastic Medicaid ID card. Providers must view the electronic eligibility display to verify the QMB category of service. The category of service for a QMB will reflect QMB-AA, QMB-AB or QMB-AD. The system will display the current eligibility. Most providers are not federally mandated to accept Medicare assignment (See Section ). However, if a physician (by Medicare s definition) or non-physician provider desires Medicaid reimbursement for coinsurance or deductible on a Medicare claim, he or she must accept Medicare assignment on that claim (see Section D) and enter the information required by Medicare on assigned claims. When a provider accepts Medicare according to Section D, the beneficiary is not responsible for the difference between the billed charges and the Medicare allowed amount. Medicaid will pay a QMB s or Medicare/Medicaid dual eligible s Medicare cost sharing (less any applicable Medicaid cost sharing) for Medicare covered services. Interested individuals may be directed to apply for the QMB program at their local Department of Human Services (DHS) county office Qualifying Individuals-1 (QI-1) The Balanced Budget Act of 1997, Section 4732, (Public law ) created the Qualifying Individuals- 1 (QI-1) aid category. Individuals eligible as QI-1 are not eligible for Medicaid benefits. They are eligible only for the payment of their Medicare Part B premium. No other Medicare cost sharing charges will be covered. Individuals eligible for QI-1 do not receive a Medicaid card. Additionally, unlike QMBs and

9 SMBs, they may not be certified in another Medicaid category for simultaneous periods. Individuals who meet the eligibly requirements for both QI-1 and medically needy spend down must choose which coverage they want for a particular period of time. Eligibility for the QI-1 program is similar to that of the QMB program. The individuals must be age 65 or older, blind or an individual with a disability and entitled to receive Medicare payment Medicare Part A hospital insurance and Medicare Part B medical insurance. Countable income must be at least 120% but less than 135% of the current Federal Poverty Level. Countable resources may equal but not exceed twice the current SSI resource limitations Specified Low-Income Medicare Beneficiaries (SMB) The Specified Low-Income Medicare Beneficiaries Program (SMB) was mandated by Section 4501 of the Omnibus Budget Reconciliation Act of Individuals eligible as specified low-income Medicare beneficiaries (SMB) are not eligible for the full range of Medicaid benefits. They are eligible only for Medicaid payment of their Medicare Part B premium. No other Medicare cost sharing charges will be covered. SMB individuals do not receive a Medicaid card. Eligibility criteria for the SMB program are similar to those for QMB program. The individuals must be aged 65 or older, blind or an individual with disabilities and entitled to receive Medicare Part A hospital insurance and Medicare Part B insurance. Their countable income must be greater than, but not equal to, 100% of the current Federal Poverty Level and less than, but not equal to, 120% of the current Federal Poverty Level. The resource limit may be equal to but not exceed twice the current SSI resource limitations. Interested individuals may apply for SMB eligibility at their local Department of Human Services (DHS) county office Reserved Reserved Beneficiary Aid Categories with Additional Cost Sharing Certain programs require additional cost sharing for Medicaid services. These programs are discussed in Sections through ARKids First-B Covered services provided to ARKids First-B participants are (with only a few exceptions) within the same scope of services provided to other Arkansas Medicaid beneficiaries, but may be subject to cost sharing requirements. See Section II of the ARKids First-B provider manual for a list of services that require cost sharing and the amount of participant liability for each service TEFRA Eligibility category 49 contains children under age 19 who are eligible for Medicaid services as authorized by Section 134 of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) and amended by the Omnibus Budget Reduction Act. Children in category 49 receive the full range of Medicaid services. However, there are cost sharing requirements. Some parents are required to pay monthly premiums according to the chart below.

10 TEFRA Cost Share Schedule Family Income Monthly Premiums From To % From To $0 $25, % $0 $0 $25,001 $50, % $21 $42 $50,001 $75, % $52 $78 $75,001 $100, % $94 $125 $100,001 $125, % $146 $182 $125,001 $150, % $208 $250 $150,001 $175, % $281 $328 $175,001 $200, % $365 $417 $200,001 And above 2.75% $458 $458 The maximum premium is $5,500 per year ($458 per month) for income levels of $200,001 and above. The premiums listed above represent family responsibility. They will not increase if a family has more than one TEFRA eligible child Working Disabled The Working Disabled category is an employment initiative designed to enable people with disabilities to gain employment without losing medical benefits. Individuals who are ages 16 through 64, with a disability as defined by Supplemental Security Income (SSI) criteria and who meet the income and resource criteria may be eligible in this category. There are two levels of cost sharing in this aid category, depending on the individual s income: A. Regular Medicaid cost sharing. Beneficiaries with gross income below 100% of the Federal Poverty Level (FPL) are responsible for the regular Medicaid cost sharing (pharmacy, inpatient hospital and prescription services for eyeglasses). They are designated in the system as WD RegCO. B. New cost sharing requirements. Beneficiaries with gross income equal to or greater than 100% FPL have cost sharing for more services and are designated in the system as WD NewCo. The cost sharing amounts for the WD NewCo eligibles are listed in the chart below: Program Services ARChoices Waiver Services Ambulance Ambulatory Surgical Center Audiological Services New Co-Payment* None $10 per trip $10 per visit $10 per visit

11 Program Services Augmentative Communication Devices Child Health Management Services Chiropractor Dental Developmental Disability Treatment Center Services Diapers, Underpads and Incontinence Supplies Domiciliary Care Durable Medical Equipment (DME) Emergency Department: Emergency Services Emergency Department: Non-emergency Services End Stage Renal Disease Services Early and Periodic Screening, Diagnosis and Treatment Eyeglasses Family Planning Services Federally Qualified Health Center (FQHC) Hearing Aids (not covered for individuals ages 21 and over) Home Health Services Hospice Hospital: Inpatient Hospital: Outpatient Hyperalimentation Immunizations Laboratory and X-Ray Medical Supplies Inpatient Psychiatric Services for Under Age 21 New Co-Payment* 10% of the Medicaid maximum allowable amount $10 per day $10 per visit $10 per visit (no co-pay on EPSDT dental screens) $10 per day None None 20% of Medicaid maximum allowable amount per DME item $10 per visit $10 per visit None None None None $10 per visit 10% of Medicaid maximum allowable amount $10 per visit None 25% of the hospital s Medicaid per diem for the first Medicaid-covered inpatient day $10 per visit 10% of Medicaid maximum allowable amount None $10 per encounter, regardless of the number of services per encounter None 25% of the facility s Medicaid per diem for the first Medicaid-covered day

12 Program Services Outpatient Behavioral Health Nurse Practitioner Private Duty Nursing Certified Nurse Midwife Orthodontia (not covered for individuals ages 21 and older) Orthotic Appliances Personal Care Physician Podiatry Prescription Drugs Prosthetic Devices Rehabilitation Services for Persons with Physical Disabilities (RSPD) Rural Health Clinic Targeted Case Management Occupational Therapy (Age 21 and older have limited coverage**) Physical Therapy (Age 21 and older have limited coverage**) Speech Therapy (Age 21 and older have limited coverage**) Transportation (non-emergency) Ventilator Services Visual Care New Co-Payment* $10 per visit $10 per visit $10 per visit $10 per visit None 10% of Medicaid maximum allowable amount None $10 per visit $10 per visit $10 for generic drugs; $15 for brand name 10% of Medicaid maximum allowable amount 25% of the first covered day s Medicaid inpatient per diem $10 per core service encounter 10% of Medicaid maximum allowable rate per unit $10 per visit $10 per visit $10 per visit None None $10 per visit * Exception: Cost sharing for nursing facility services is in the form of patient liability which generally requires that patients contribute most of their monthly income toward their nursing facility care. Therefore, WD beneficiaries (Aid Category 10) who temporarily enter a nursing home and continue to meet WD eligibility criteria will be exempt from the co-payments listed above. ** Exception: This service is NOT covered for individuals within the Occupational, Physical and Speech Therapy Program for individuals ages 21 and older. NOTE: Providers must consult the appropriate provider manual to determine coverage and benefits.

13 PCMH Deadlines Enrollment for the 2017 Arkansas Medicaid PCMH performance period will begin August 15, 2016 and end October 31, More information can be found on the payment initiative web site at: Process.aspx

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15 Outreach Update Patient-Centered Medical Home (PCMH) enrollment is now open Enrollment in the PCMH program is voluntary and practices must re-enroll annually. PCMH enrollment is Sept. 1 through Oct. 31, To enroll, practices must access the AHIN portal and submit a complete and accurate Arkansas Medicaid Patient-Centered Medical Home Practice Participation Agreement (DMS- 844). This application is only available on the AHIN web site. The completed application will be submitted to ARKPCMH@hpe.com. No faxes will be received. If you are currently enrolled in PCMH, you should have received a completed application from ARKPCMH@hpe.com. Providers who are already enrolled with your PCMH clinic will not require additional signatures; however, a signature will be required for any new providers on the enrollment application. Pooling forms are also due by Oct. 31, If you have any questions, your AFMC Outreach Specialist or HPE at ARKPCMH@hpe.com / can assist.

16 PCMH Manual: Enrollment Eligibility To be eligible to enroll in the PCMH program: A. The entity must be a participating practice as defined in Section B. The practice must include PCPs enrolled in the ConnectCare Primary Care Case Management (PCCM) Program. C. The practice may not participate in the PCCM shared savings pilot established under Act 1453 of D. The practice must have at least 300 attributed beneficiaries at the time of enrollment. DMS may modify the number of attributed beneficiaries required for enrollment based on provider experience and will publish at any such modification. E. The practice must meet eligibility criteria as specified in the conditions for enrollment as indicated in the PCMH activities and metrics list. These criteria are published on the APII website at DEFINITIONS Participating practice: A physician practice that is enrolled in the PCMH program, which must be one of the following: A. An individual primary care physician (Provider Type 01 or 03); B. A physician group of primary care providers who are affiliated, with a common group identification number (Provider Type 02, 04 or 81); C. A Rural Health Clinic (Provider Type 29) as defined in the Rural Health Clinic Provider Manual Section ; or D. An Area Health Education Center (Provider type 69) Practice Enrollment Enrollment in the PCMH program is voluntary and practices must re-enroll annually. To enroll, practices must access the Advanced Health Information Network (AHIN) provider portal and submit a complete and accurate Arkansas Medicaid Patient-Centered Medical Home Practice Participation Agreement (DMS-844). The AHIN portal can be accessed at

17 Once enrolled, a participating PCMH remains in the PCMH program until: A. The PCMH withdraws; B. The practice or provider changes ownership, becomes ineligible, is suspended or terminated from the Medicaid program or the PCMH program; or C. DMS terminates the PCMH program. A physician may be affiliated with only one participating practice. A participating practice must update the Department of Human Services (DHS) on changes to the list of physicians who are part of the practice. Physicians who are no longer participating within a practice are required to update in writing via at ARKPCMH@hpe.com within 30 days of the change. To withdraw from the PCMH program, the participating practice must a complete and accurate Arkansas Patient-Centered Medical Home Withdrawal Form (DMS-846) to ARKPCMH@hpe.com. View or print the Arkansas Patient-Centered Medical Home Withdrawal Form (DMS-846) on the APII website at or download the form from the AHIN provider portal Pools of Attributed Beneficiaries Shared savings entities will meet the minimum pool size of 5,000 attributed beneficiaries as described in Section in one of three ways: Patient-Centered Medical Home Section II Section II-7 A. Meet minimum pool size independently; B. B. Pool attributed beneficiaries voluntarily with other participating PCMHs as described in Section ; or C. Be assigned to the default pool as described in Section In the methods B and C listed above, PCMHs have their performance measured together by aggregating performance of the per beneficiary cost of care. In the method B, the quality metrics are tracked for shared savings incentive payments across all the PCMHs in the pool. In the method C, the quality metrics are tracked for shared savings incentive payments on an individual PCMH level. A shared savings entity s configuration (A, B or C) is established during the enrollment period and cannot be changed after the end of the enrollment period.

18 Requirements for Joining and Leaving Pools PCMHs may voluntarily pool for purposes described in Section before the end of the enrollment period that precedes the start of the performance period. To pool, the participating practice must a complete and accurate Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Form (DMS-845) to ARKPCMH@hpe.com. View or print the Arkansas Medicaid Patient-Centered Medical Home Program Pooling Request Form on the APII website at You can also download the form from the AHIN provider portal. The DMS-845 Pooling form must be executed by all PCMHs participating in the pool. Before the end of the enrollment period, PCMHs that are on their own or through pooling do not reach a minimum of 5,000 attributed beneficiaries will be assigned to the default pool. Individual PCMHs whose attribution changes during the performance period will be classified as standalone or default pool members according to their attribution count at the end of the performance period. This exception does not apply to voluntary pools. Pooling is effective for a single performance period and must be renewed for each subsequent year. When a PCMH has voluntarily pooled, its performance is measured in the associated shared savings entity throughout the duration of the performance period unless it withdraws from the PCMH program during the performance period. When a PCMH in the voluntary pool withdraws from the PCMH program, any and all PCMHs in the shared savings entity will have their performance measured as if the withdrawn PCMH had never participated in the pool.

19 Research, Reconsideration and Appeals Provider Reports DMS provides participating PCMH provider reports containing information about their PCMH performance on activities tracked for practice support, quality metrics tracked for shared savings incentive payments and their per beneficiary cost of care via the provider portal. Providers who have concerns about information included in their reports should send an to The PCMH Quality Assurance Manager will respond to the provider/practice with a review of their inquiry. If the review leads to a discovery that the provider report is inaccurate or does not reflect actual performance, DMS will take the necessary steps to correct the inaccuracies including those that are a result of a systems and/or algorithm error. Providers can also call the APII help desk at or and by at ARKPII@HPE.com. A. Appeals If you disagree with DMS decision regarding program participation, payment or other adverse action, you have the right to request reconsideration and you have the right to request an administrative appeal. B. Request Reconsideration The Division of Medical Services must receive written request for reconsideration within (30) calendar days of the Date of the adverse action, notice. Send your request to the Director, Division of Medical Services P.O. Box 1437, Slot S401, Little Rock, AR C. Request an Administrative Appeal The Arkansas Department of Health must receive a written appeals request within (30) calendar days of the date of the adverse action notice, or within (10) calendar days of receiving a reconsideration decision. Send your request to Arkansas Department of Health: Attention: Medicaid Provider Appeals Office, 4815 West Markham Street, Slot 31, Little Rock, AR

20 PCMH Recovery of Practice Support Practice support is suspended/terminated if the practice fails to remediate within the required time. When a practice files an appeal because they feel that they were improperly suspended, the practice is treated like an enrolled practice during the appeal process. Quality Assurance (QA) will continue to validate, the practice will continue to receive reports, and continue to receive payments but if the judge agrees with DMS decision to suspend, the suspension date is retroactively applied. Any financial incentive received after the suspension date is recouped as the practice was not enrolled in the program Accountability for Practice Support If a PCMH does not meet deadlines and targets for activities tracked for practice support as described in Section , then the practice must remediate its performance to avoid suspension or termination of practice support. DMS will verify whether attestation and required documentation was submitted as required by the PCMH program. Failure to comply with this requirement will result in a Notice of Attestation Failure. DMS will also validate whether attested activities met the PCMH program requirements. Failure to pass validation will result in a Notice of Validation Failure. PCMHs which received a Notice of Attestation Failure and/or PCMHs which received a Notice of Validation Failure will have 15 calendar days to submit sufficient QIP. Failure to submit sufficient QIP within 15 days of receiving a Notice of Attestation Failure and/or a Notice of Validation Failure will result in suspension or termination of practice support. PCMHs which receive a Notice of Attestation Failure will have 90 days to remediate their performance from the date of the Notice of Attestation Failure. PCMHs which received a Notice of Validation Failure will have 45 days to remediate their performance from the date of the Notice of Validation Failure. If a PCMH fails to meet the deadlines or targets for activities within the specified remediation time, then DMS will suspend or terminate practice support.

21 PCMH Contacts: Arkansas Foundation for Medical Care (AFMC) Provider Outreach Specialists Phone: Website: AFMC Provider Outreach ensures that practices have knowledge of the benefits and requirements to become a successful PCMH assisting with enrollment applications, reading of reports and portal navigation. Provider Outreach Specialists act as the gatekeeper between providers and vendors facilitating providers in getting what they need. Hewlett Packard Enterprise Services (HPE) APII Help Desk: or Fax: General Inquiries: ARKPII@hpe.com Enrollment applications only: ARKPCMH@hpe.com HPE assists with processing of enrollment applications and researching specific report metrics upon request. HPE assist with any payment issues related to the PCMH program. Arkansas Foundation for Medical Care, Practice Transformation Rhelinda McFadden, RN, CPHIT, CPEHR Manager, PCMHPT/Quality Consultant 1020 West 4 th Street, Suite 200 Little Rock, Arkansas Phone: Fax: rmcfadden@afmc.org pcmhpt@afmc.org Website: AFMC PT works directly with providers / PCMHs to educate on and implement PCMH Activities and Metrics through customized support to actively address barriers, manage change and improve outcomes of the PCMH. Updated 10/18/16 - AFMC

22 PRIOR AUTHORIZATION Procedures for Obtaining Prior Authorization There are certain medical, diagnostic and surgical procedures that are not covered without prior authorization, either because of federal requirements or because of the elective nature of a procedure. Arkansas Foundation for Medical Care, Inc.(AFMC), under contract with Arkansas Medicaid, makes prior authorization (PA) determinations for most Medicaid-covered surgical procedures that require PA, and for some lab procedures that require PA. Please refer to Section of this manual for a list of procedures requiring prior authorization. Prior authorization determinations are made utilizing established medical or administrative criteria combined with the professional judgment of AFMC s physician advisors. Written documentation is not required. However, the oral information given to AFMC when requesting prior authorization must be substantiated by medical record documentation and reports upon AFMC and/or State retrospective reviews. It is the responsibility of the physician who will perform the procedure to initiate the prior authorization request. When requesting prior authorization, the physician or the physician s office nurse must contact AFMC. View or print AFMC contact information. The physician or the physician s office nurse must furnish the following specific information to AFMC: (All calls are tape recorded.) A. Patient Name and Address B. Recipient Medicaid Identification Number C. Physician Name and License Number D. Physician provider identification number E. Hospital Name F. Date of Service for Requested Procedure G. Card Issuance Date for Retroactive Eligibility Authorizations When you call, please provide all patient identification information and medical information related to the necessity of the procedure you need authorized. AFMC will give approval or denial of the request by phone with follow-up in writing. If approval is granted, AFMC will assign a prior authorization control number that must be entered in the appropriate field of the claim when billing for the procedure. If surgery is involved, a copy of the authorization will be mailed to the hospital where the service will be performed. If the hospital has not received a copy of the authorization before the time of admission, the hospital will contact the admitting physician or AFMC to verify that prior authorization has been granted. It is the responsibility of the primary surgeon to distribute a copy of the authorization to the assistant surgeon if the assistant has been requested and approved. Prior authorization of service does not guarantee eligibility for a beneficiary. Coverage is contingent on the beneficiary s eligibility on the date(s) of service Post-authorization for Emergency Procedures and Periods of Retroactive Eligibility Post-authorization will be granted only for emergency procedures and/or retroactively eligible recipients. A. Requests for emergency procedures must be applied for on the first working day after the procedure has been performed.

23 B. In cases of retroactive eligibility, AFMC must be contacted for post-authorization within 60 days of the eligibility card issuance date. C. In cases involving a hysterectomy, documentation must be provided that reflects the acknowledgement statement was signed prior to surgery or the attending physician must certify in writing: (Use form DMS View or print form DMS-2606.) 1. That the individual was already sterile, stating the cause of sterility; or 2. That the hysterectomy was performed under a life threatening emergency situation in which the physician determined prior acknowledgement was not possible. The physician must also include a description of the nature of the emergency. FORM DMS-2606 MUST BE ATTACHED TO THE CLAIM FOR PAYMENT. The document must be reviewed and approved by the Medicaid Program before payment will be considered. It should be stressed that all guidelines must be met in order for payment to be made Reserved Post Procedural Authorization for Eligible Recipients Under Age Providers performing surgical procedures that require prior authorization are allowed 60 days from the date of service to obtain prior authorization if the recipient is under age 21. All requests for post-procedural authorizations for eligible recipients are to be made to the Arkansas Foundation for Medical Care, Inc., (AFMC) by telephone within 60 days of the date of service. These calls will be tape-recorded. View or print AFMC contact information. AFMC must be provided the recipient and provider identifying criteria and all of the medical data necessary to justify the procedures. As medical information will be exchanged for this procedure, these calls must be made by the physician or a member of his or her nursing staff. The provider will be issued a PA number at the time of the call if the procedure requested is approved. A follow-up letter will be mailed the same day to the physician. Consulting physicians are responsible for calling AFMC to have procedures added to the PA file. They will be given the prior authorization number at the time of the call on cases that are approved. A letter verifying the PA number will be sent to the consultant upon request. When calling, all patient identification information and medical information related to the necessity of the procedure needing authorization must be provided. The Arkansas Medicaid Program recommends providers obtain prior authorization for procedures requiring authorization in order to prevent risk of denial due to lack of medical necessity. This policy applies only to those Medicaid recipients under age 21. This policy does not alter prior authorization procedures applicable to retroactive eligible recipients.

24 Procedures that Require Prior Authorization The procedures represented by the CPT and HCPCS codes in the following table require prior authorization (PA). The performing physician or dentist (or the referring physician or dentist, when lab work is ordered or injections are given by non-physician staff) is responsible for obtaining required PA and forwarding the PA control number to appropriate hospital staff for documentation and billing purposes. A claim for any hospital services that involve a PA-required procedure must contain the assigned PA control number or Medicaid will deny it. (See Sections through of this manual for instructions for obtaining prior authorization.) See Section for billing instructions for Molecular Pathology codes J7330 S2066 S2067 S2112 S Prior Approval and Due Process Information A. Organ transplants in Arkansas and in states that border Arkansas require prior approval from Arkansas Medicaid. B. In states that do not border Arkansas, organ transplants and organ transplant evaluations require prior approval from Arkansas Medicaid Organ Transplant Prior Approval in Arkansas and Bordering States The attending physician is responsible for obtaining prior approval for organ transplants.

25 A. The attending physician submits his or her transplant evaluation (workup) results to the Utilization Review (UR) Section, requesting approval of the transplant. View or print the UR Section contact information. B. UR forwards the request and its supporting documentation to Arkansas Foundation for Medical Care, Inc. (AFMC) for a determination of approval or denial. C. AFMC advises the requesting physician and the beneficiary of its decision Organ Transplant and Evaluation Prior Approval in Non- Bordering States A. In states that do not border Arkansas, prior approval is required for organ transplant evaluations and organ transplants. B. The attending physician is responsible for obtaining prior approval for organ transplant evaluations and organ transplants. 1. The attending physician must request from the UR Section prior approval of a transplant evaluation, identifying the facility at which the evaluation is to take place and the physician who will conduct the evaluation. View or print the UR Section contact information. 2. UR reviews the physician s request for transplant evaluation and forwards its approval to the facility at which the referring physician has indicated the evaluation will take place. 3. The evaluation results must be forwarded to UR with a request for approval of the transplant procedure. 4. UR forwards the request and the supporting documentation to AFMC for a determination of approval or denial. 5. AFMC advises the requesting physician and the beneficiary of its decision Hyperbaric Oxygen Therapy (HBOT) Prior Authorization All hyperbaric oxygen therapy will require prior authorization, except in emergency cases such as for air embolism or carbon monoxide poisoning, in which post-authorization will be allowed per protocol. See Section Prior authorization will be for a certain number of treatments. Further treatments will require reapplication for a prior authorization. In order to request a prior authorization for HBOT, the provider must call the AFMC prior authorization number, (800) Refer to Sections , , , and for additional information on HBOT.

26 Prior Authorization of Hyaluronon (Sodium Hyaluronate) Injection Prior authorization is required for coverage of the Hyaluronon (sodium hyaluronate) injection. Providers must specify the brand name of Hyaluronon (sodium hyaluronate) or derivative when requesting prior authorization for the following procedure codes: J7321 J7323 J7324 J7325 A written request must be submitted to Division of Medical Services Utilization Review Section. View or print the Division of Medical Services Utilization Review Section address. The request must include the patient s name, Medicaid ID number, physician s name, physician s provider identification number, patient s age, and medical records that document the severity of osteoarthritis, previous treatments and site of injection. Hyaluronon is limited to one series of injections per knee, per beneficiary, per lifetime.

27 Division of Medical Services Program Development & Quality Assurance P.O. Box 1437, Slot S295 Little Rock, AR Fax: TDD/TTY: TO: All Hospital Providers DATE: July 1, 2016 SUBJECT: Update on the Removal of the 24-day Cap As of July 1, 2016, the Department of Human Services, Division of Medical Services has completed the payment system modifications to remove the 24-day cap on inpatient hospital days effective for dates of service on or after January 1, The MUMP (Medicaid Utilization Management Program) reviews through AFMC are still required as stated in current policy. See Section of the Hospital Manual. At this time, system changes to implement the Crossover payment modification have not been completed. A notice will be sent out in the coming weeks with more information. Hospitals are encouraged to be prepared for recoupments of overpayments due to the delay in the implementation of the inpatient crossover payment modification. If you have any questions regarding this memo, please contact the Division of Medical Services, Institutional Reimbursement Unit at (501) Thank you for your participation in the Arkansas Medicaid Program. humanservices.arkansas.gov Protecting the vulnerable, fostering independence and promoting better health

28 Best Practices for Providing After-Hours Care Providing full continuity of care for patients requires physicians to provide some sort of system to handle patient crises after hours and on weekends. When communication is not available, patients either seek more expensive ER care or deteriorate, leading to more serious complications. Providing 24/7 physician communications is evolving as a professional standard of care and is an integral part of the medical home. Where improved after-hours communications have been implemented, patient satisfaction has increased and ER utilization has declined. BEST PRACTICES PCPs should have an after-hours system in place that ensures that patients can reach the PCP or another on-call medical professional with medical concerns or questions. This system should connect callers with a live voice either an answering service or afterhours personnel who should either forward patient calls directly to the on-call professional or instruct callers that the professional will return the call within 30 minutes. The answering service or after-hours personnel should ask the caller if the situation is an emergency. If so, the caller should be told to call 911 or go straight to the nearest ER. If staff or an answering service is not immediately available, the PCP/clinic may use an answering machine with a recorded message that directs callers to call 911 if they have an emergency, and to dial an alternate number (or system prompt) to reach an on-call professional. PCPs may provide access to an on-call professional through arranging with other PCPs to rotate call, or by contracting with a triage hotline service staffed by nurses or other clinical personnel. Records of after-hours calls should be made and entered into the patient s chart. AFTER-HOURS CARE PRACTICE ASSESSMENT To gauge your practice s performance in providing after-hours care, answer the following questions: Does your clinic provide access to a medical professional either an on-call provider or a telephone triage service staffed by clinical personnel to give callers voice-to-voice medical advice and guidance 24 hours, seven days a week? Does your clinic use an answering service or clinic staff to answer after-hours calls? If not, does your clinic use an answering machine that directs callers to dial an alternate number or system prompt to reach a live voice? If your clinic uses an answering machine, do you check it regularly to make sure it s working properly and the recorded message is current? Are non-emergency calls returned by a medical professional within 30 minutes? Are after-hours calls and their results documented and entered into patient records?

29 Example answering machine greeting ➊ You have reached [clinic name]. ➋ If this is an emergency, please hang up and dial 911 or go to the nearest hospital emergency room. ➌ If this is not an emergency and you would like to speak ➍ to an on-call doctor or nurse, please dial [answering service, on-call pager number, triage hotline number, etc.]. If the alternate number is to an on-call pager, add: A medical professional will return your call within 30 minutes. PROCESS FOR RECORDING AFTER-HOURS CALLS INTO A PATIENT S CHART FOLLOW UP: Contact patient and set appointment Check answering machine Retrieve messages Retrieve patient s chart Document call in chart FOLLOW UP: Contact patient and give referral For more information, contact your AFMC Provider Relations Outreach Specialist. FOLLOW UP: Contact patient and counsel THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) PURSUANT TO A CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT.

30 PCMH Recovery of Practice Support Practice support is suspended/terminated if the practice fails to remediate within the required time. When a practice files an appeal because they feel that they were improperly suspended, the practice is treated like an enrolled practice during the appeal process. Quality Assurance (QA) will continue to validate, the practice will continue to receive reports, and continue to receive payments but if the judge agrees with DMS decision to suspend, the suspension date is retroactively applied. Any financial incentive received after the suspension date is recouped as the practice was not enrolled in the program Accountability for Practice Support If a PCMH does not meet deadlines and targets for activities tracked for practice support as described in Section , then the practice must remediate its performance to avoid suspension or termination of practice support. DMS will verify whether attestation and required documentation was submitted as required by the PCMH program. Failure to comply with this requirement will result in a Notice of Attestation Failure. DMS will also validate whether attested activities met the PCMH program requirements. Failure to pass validation will result in a Notice of Validation Failure. PCMHs which received a Notice of Attestation Failure and/or PCMHs which received a Notice of Validation Failure will have 15 calendar days to submit sufficient QIP. Failure to submit sufficient QIP within 15 days of receiving a Notice of Attestation Failure and/or a Notice of Validation Failure will result in suspension or termination of practice support. PCMHs which receive a Notice of Attestation Failure will have 90 days to remediate their performance from the date of the Notice of Attestation Failure. PCMHs which received a Notice of Validation Failure will have 45 days to remediate their performance from the date of the Notice of Validation Failure. If a PCMH fails to meet the deadlines or targets for activities within the specified remediation time, then DMS will suspend or terminate practice support.

31 Research, Reconsideration and Appeals Provider Reports DMS provides participating PCMH provider reports containing information about their PCMH performance on activities tracked for practice support, quality metrics tracked for shared savings incentive payments and their per beneficiary cost of care via the provider portal. Providers who have concerns about information included in their reports should send an to The PCMH Quality Assurance Manager will respond to the provider/practice with a review of their inquiry. If the review leads to a discovery that the provider report is inaccurate or does not reflect actual performance, DMS will take the necessary steps to correct the inaccuracies including those that are a result of a systems and/or algorithm error. Providers can also call the APII help desk at or and by at ARKPII@HPE.com. A. Appeals If you disagree with DMS decision regarding program participation, payment or other adverse action, you have the right to request reconsideration and you have the right to request an administrative appeal. B. Request Reconsideration The Division of Medical Services must receive written request for reconsideration within (30) calendar days of the Date of the adverse action, notice. Send your request to the Director, Division of Medical Services P.O. Box 1437, Slot S401, Little Rock, AR C. Request an Administrative Appeal The Arkansas Department of Health must receive a written appeals request within (30) calendar days of the date of the adverse action notice, or within (10) calendar days of receiving a reconsideration decision. Send your request to Arkansas Department of Health: Attention: Medicaid Provider Appeals Office, 4815 West Markham Street, Slot 31, Little Rock, AR

32 Arkansas Medicaid Emergency Room Flow Chart PATIENT PRESENTS AT THE ER TRIAGE MEDICAL ASSESSMENT* Revised January 2016 NON-EMERGENCY EMERGENCY Determine if the patient has Medicaid Treat ENROLL Treat Refer to PCP Submit non-emergency claim to Medicaid (Rev. code 459) and enrollment fee (Rev. code 960) Enrolled with PCP? NO YES PCP gives referral for treatment Treat Submit non-emergency claim to Medicaid (Rev. code 459) CONTACT PCP FOR INSTRUCTIONS AND/OR REFERRAL Patient asked for treatment Bill patient Submit emergency claim to Medicaid (Rev. code 450) PCP refuses referral for treatment Refer patient to PCP Submit assessment claim (Rev. code 451) *Medical assessment performed by qualified medical personnel. THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) PURSUANT TO A CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. (8717, 1/16)

33 Emergency Room Trend Report These reports breakdown emergency room visits by the following: Facility Assessment, Non- Emergency, and Emergency. It also provides the emergency visits by age, top five diagnoses for all hospitals and it gives statewide totals of emergency services usage. The Emergency Room Trend Reports are mailed directly to the facility. If you aren t receiving these reports, or if more information is needed, please contact Gina Redford, M.A.P., Program Manager, Health Services Advisory Group, at or via at gredford@hsag.com.

34 Sign Up for iexchange Today AFMC s online review submission and tracking application saves providers time and money. Advantages of signing up with iexchange : n All transactions are free to the provider n Available 24 hours a day, seven days a week n Can be accessed anywhere with an Internet connection n HIPAA compliant and secure n Providers can: > Perform searches > Determine status of submitted requests (pending, approved, denied, partial) > Request reconsideration electronically > Attach records and communicate through notes n Cuts postage costs n More efficient and effective way to submit requests/medical records Visit the AFMC website at afmc.org/iexchange n Complete the request form and a Medecision representative will contact you via with an administrative user ID for your office/facility login information n The administrator(s) for each provider group/facility has the ability to add additional users through iexchange for the unique account number assigned for each provider group/facility n A username, iexchange ID, and password will be required for each user n The iexchange ID is a unique account number assigned for each provider group/facility iexchange transaction n The iexchange login screen can be accessed from the AFMC website and saved to your favorites or a shortcut can be added to your desktop Use iexchange to submit: n Inpatient requests (including inpatient retrospective chart requests and concurrent reviews [MUMP]) n Other requests (emergency department chart requests, therapy chart requests) n Providers may submit requests and records for the following as well: Durable medical equipment (DME), extension of benefits (EOB), prior authorization (PA) requests (medical/surgical procedures/assistant surgeon), hyperalimentation, wheelchairs, Child Health Management Services (CHMS), physician drug reviews, personal care and molecular pathology You can also perform: n Member search n Provider search n Treatment search and treatment update search n Member ID/search capability Online training resources are available on AFMC s website: afmc.org/iexchange AFMC Provider Helpdesk or webreview@afmc.org Tips > Always choose a treatment setting > Only choose prior auth for surgical procedures and MUMPS

35 Arkansas Foundation for Medical Care Other (Outpatient Transaction) Tip Sheet Proprietary and Confidential 2015 Medecision, Inc. Proprietary and Confidential

36 Getting Started» Login information is case sensitive» User ID, iexchange ID and Password are required» Users will be prompted to change passwords every 30 days» System time out» If there is no activity for a period of 60 minutes, you will be timed out of iexchange and you will receive the message:» "Your session has expired. Please, login again."» Do not use the Back button to navigate in iexchange» At the bottom of most pages you will see buttons (such as Cancel, Back, or New Search ) that allow you to return to previous pages» You can click the Starting point block in the upper left hand corner at any time to return to the main page 2015 Medecision, Inc. Proprietary and Confidential

37 Arkansas Foundation for Medical Care iexchange Training New Other (Outpatient) request Proprietary and Confidential 2015 Medecision, Inc. Proprietary and Confidential

38 Request Submission» Each request has three stages 1. Request Entry» All fields should be completed unless marked as (optional)» System administrators can add frequently used providers, diagnoses and procedures to facilitate data entry» Additional Notes (iexchange Clinical Information) text box at the bottom of the page should be used to indicate if documents will be attached to the request» Click at the bottom of the screen to proceed to the Preview page 2. Request Preview» Allows you to review request information a final time before submitting» Displays Outcome Status of the request if it is submitted as is» Allows you to return to entry page and edit if necessary click at the bottom of the screen» You can add additional services by clicking at the bottom of the screen or if no additional services are required click 3. Request Confirmation» Displays the Outcome Status and request ID» Displays same information as Preview page» To open print friendly version of this page click» You can click to the right of the Request ID if a document needs to be attached to the request 2015 Medecision, Inc. Proprietary and Confidential

39 Select New Other Request 2015 Medecision, Inc. Proprietary and Confidential

40 Information about member search Information about Treatment setting 2015 Medecision, Inc. Proprietary and Confidential 2015 Medecision, Inc. Proprietary and Confidential

41 Instructions about procedure codes and including notes at the bottom Click Next step to continue 2015 Medecision, Inc. Proprietary and Confidential

42 Preview page includes projected status of the request and allows the user to verify the accuracy of the information prior to final submission request can be edited, submitted, or cancelled 2015 Medecision, Inc. Proprietary and Confidential

43 Confirmation page includes the Request ID and allows the user to attach additional required information to support the request 2015 Medecision, Inc. Proprietary and Confidential

44 Request Attachments» Users can attach documents to any existing authorization request in iexchange» Follow the below steps to add attachments 1. You can click to the right of the Request ID if a document needs to be attached to the request 2. Enter a title for the document to be attached 3. Click to select or locate the file to be attached 4. Click to add the document 5. Click OK in the popup window to continue or cancel if the attachment was selected in error 6. Information message will appear at the top of the page to indicate that the file has been successfully attached 2015 Medecision, Inc. Proprietary and Confidential

45 Request Attachments Confirmation page 1 Click Attach file 2 and 3 Enter a document title and select Browse to select a document Medecision, Inc. Proprietary and Confidential

46 Request Attachments Confirmation page 4 Click Attach 5 Click OK to attach the document to the request Medecision, Inc. Proprietary and Confidential

47 Request Attachments Confirmation page 6 Message at the top will confirm the attachment has been sent or is in progress Medecision, Inc. Proprietary and Confidential

48 iexchange Overview Ideal for both BENEFITS INCLUDE: administrative and Simple to use clinical staff users, Free to providers iexchange is a Reduces time and expense of paper, telephone and fax processes web-based solution that allows providers to securely submit health care transactions directly to AFMC. Secure site Available 24/7 Allows providers to review results for all their requests submitted Allows providers to receive treatment updates when requests are modified or the status has changed Outpatient and inpatient medical records that can be submitted for review via iexchange include retrospective review (RETRO), Child Health Management Services (CHMS), extension of benefits (EOB), prior authorization of medical and surgical procedures, emergency room, durable medical equipment (DME), hyperalimentation, therapy and concurrent reviews of inpatient stays (MUMP) to mention a few. Any type of review that we perform can be submitted via iexchange. Thank you for your time and consideration of iexchange. We look forward to working with you and your staff. FOR MORE INFORMATION, CONTACT Jarrod McClain, RN, CPHM Director, Clinical Review, AFMC jmcclain@afmc.org CENTRAL MALL 5111 ROGERS AVE., SUITE 476 FORT SMITH, AR

49 ARKids Full Preventive Health Screen Billing Procedures ARKIDS A: EPSDT SCREEN NEWBORN PROCEDURE CODE BY AGE < 1 YEAR 1 4 YEARS 5 11 YEARS YEARS YEARS MODIFIERS MODIFIER 1 MODIFIER 2 New patient EP U1 Established patient EP U2 Newborn in hospital Newborn in other setting < 1 NEWBORN YEAR ARKIDS B: PREVENTIVE HEALTH SCREEN ARKids A must choose Special Program Code : Initial hospital/birthing center care/normal newborn 99463: Initial hospital/birthing center normal NB admitted/discharged same date of service 99461: Initial care normal newborn other than hospital/birthing center PROCEDURE CODE BY AGE 1 4 YEARS 5 11 YEARS YEARS 18 YEARS EP EP UA UA MODIFIERS MODIFIER 1 MODIFIER 2 New patient NO MODIFIERS Established patient FOR ARKIDS B Newborn in hospital Newborn in other setting 99460: Initial hospital/birthing center care/normal newborn 99463: Initial hospital/birthing center normal NB admitted/discharged same date of service 99461: Initial care normal newborn other than hospital/birthing center (Newborn only) UA (Newborn only) UA As of May 2016 Newborn procedure codes pay $ while all other listed codes pay $ THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) PURSUANT TO A CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. (5/16)

50 ICD-10-CM Diagnosis Codes for Wellness Exams ICD-10-CM DIAGNOSIS CODES (NEWBORN) Z38.00 Single liveborn infant, delivered vaginally Z38.01 Single liveborn infant, delivered cesarean Z38.1 Single liveborn infant, born outside hospital Z38.2 Single liveborn infant, unspecified as to place of birth Z38.30 Twin liveborn infant, delivered vaginally Z38.31 Twin liveborn infant, delivered by cesarean Z38.4 Twin liveborn infant, born outside hospital Z38.5 Twin liveborn infant, unspecified as to place of birth Z38.61 Triplet liveborn infant, delivered vaginally Z38.62 Triplet liveborn infant, delivered by cesarean Z38.63 Quadruplet liveborn infant, delivered vaginally Z38.64 Quadruplet liveborn infant, delivered by cesarean Z38.65 Quintuplet liveborn infant, delivered vaginally Z38.66 Quintuplet liveborn infant, delivered by cesarean Z38.68 Other multiple liveborn infant, delivered vaginally Z38.69 Other multiple liveborn infant, delivered by cesarean Z38.7 Other multiple liveborn infant, born outside hospital Z38.8 Other multiple liveborn infant, unspecified as to place of birth ICD-10-CM DIAGNOSIS CODES Z Encounter for routine child health exam with abnormal findings Z Encounter for routine child health exam without abnormal findings Z13.4 Encounter for screening for certain childhood developmental disorders in childhood Z76.1 Encounter for health supervision and care of foundling Z76.2 Encounter for health supervision and care of other healthy infant and child THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC) PURSUANT TO A CONTRACT WITH THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICY. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. (8718, 1/16)

51 ARKANSAS MEDICAID CHILD HEALTH SERVICES (EPSDT) FEE SCHEDULE This fee schedule does not address the various coverage limitations routinely applied by Arkansas Medicaid before final payment is determined (e.g., beneficiary and provider eligibility, benefit limits, billing instructions, frequency of services, third party liability, age restrictions, prior authorization, co-payments/coinsurance where applicable, etc.). Procedure codes and/or fee schedule amounts listed do not guarantee payment, coverage or amount allowed. Although every effort is made to ensure the accuracy of this information, discrepancies and time lag may occur. All information may be changed or updated at any time to correct a discrepancy and/or error. The reimbursement rates reflected in this fee schedule are in effect as of the date of this report. The reimbursement rate made on a claim will depend on the date of service since our reimbursement rates are date of service effective. The fee schedule reflects only procedure codes that are currently payable. Any procedure code reflecting a Medicaid maximum of $0.00 is manually priced. This fee schedule only reflects the EPSDT screenings and the Vaccine for Children immunizations. You will need to access the applicable fee schedule for all other services covered for the EPSDT program. Please note that Arkansas Medicaid will reimburse the lesser of the amount billed or the Medicaid maximum. For a full explanation of the procedure codes/modifiers, refer to the information in your provider manuals. Current Dental Terminology (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright 2009 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. Run Date 5/18/12 Procedure Code TOS Mod 1 Mod 2 Mod 3 Mod 4 Plan Code Medicaid Maximum Allowed Amount EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $9.56

52 EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP TJ ZZZ $ EP ZZZ $ EP ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $56.41

53 EP H ZZZ $ EP U ZZZ $ EP H ZZZ $ EP U ZZZ $ EP ZZZ $ EP UA ZZZ $ EP UA ZZZ $ EP UA ZZZ $ V EP ZZZ $12.02 V EP ZZZ $344.75

54 EPSDT Manual: Foster Care Intake Physical Examination in the EPSDT Program Arkansas Medicaid beneficiaries entering the Arkansas foster care system are required to receive an intake physical examination within the first seventy two (72) hours. If the EPSDT provider who performs the screening is not the beneficiary s PCP, the intake physical examination should be billed with procedure codes and modifiers EP and H9. Billing with these procedure codes and modifiers will allow the claim to be submitted for payment without a referral from the beneficiary s PCP and will alert the system not to count the screen toward the beneficiary s yearly EPSDT periodic complete medical screening limits. If the EPSDT provider who performs the screen is the beneficiary s PCP, the intake physical exam should be billed with procedure codes and modifiers EP and H9. Billing with these procedure codes and modifiers will allow the claim to be submitted for payment and will not count toward the beneficiary s yearly EPSDT periodic complete medical screening limits. Procedure codes and , in conjunction with the EP and H9 modifiers, are to be used only for the required intake physical examination for Medicaid beneficiaries in the Arkansas foster care system.

55 Screenings and Sick Visits Child Health Services (EPSDT) Screenings and Sick Visits Screenings performed on the same date of service as an office visit for treatment of an acute or chronic condition may be billed as a periodic Child Health Services (EPSDT) screening, electronically or on paper using the CMS-1500 claim form. Effective for dates of service on and after May 1, 2006, a Child Health Services (EPSDT) screening performed during an office visit for treatment of an acute or chronic condition may be billed as a separate visit for the same date of service using a CPT evaluation and management procedure code. Do not use modifiers on the sick visit procedure code. The visit must be billed electronically, or on paper using a separate CMS-1500 form. View a CMS-1500 sample form Completion of the CMS-1500 Claim Form Required Reason Code location: 24H H. EPSDT/Family Plan EPSDT Reason Codes are required for EPSDT services. Please enter the appropriate 2 byte reason code in the upper shaded part of the detail line. AV Available Not Used (patient refused referral) NU Not Used (used when no EPSDT patient referral was given) S2 Under Treatment (patient is currently under treatment for referred diagnostic or corrective health problem) ST New Service Requested (Referral to another provider for diagnostic or corrective treatment/scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service, not including dental referrals.) Family Planning Indicator is not applicable for this claim type. See Sections of the EPSDT manual for specific EPSDT billing instructions. PLEASE REFER TO OFFICIAL NOTICE DATED: December 1, CMS-1500 Replaces DMS-694 for EPSDT Screenings or Services

56 Messages for Remittance Advices dated May 22, 2014 May 29, 2014 TO: ASC, AHEC, HOSPITAL, INDEPENDENT RADIOLOGY, PHYSICIAN, REHABILITATIVE HOSPITAL PROVIDERS RE: PROCEDURE CODE Arkansas Medicaid will continue to cover CPT procedure code 77417, based on its national description. HCPCS Level II "U1 through U4" modifiers are no longer utilized for reimbursement of NCCI protocols apply to TO: ALL PROVIDERS RE: NCCI AUDITING OF EPSDT/SICK VISIT RENDERED SAME DATE OF SERVICE Due to a change in CMS NCCI (National Correct Coding Initiative) auditing, Arkansas Medicaid is no longer able to process both a sick visit and EPSDT/ARKids- First B preventative screening when performed on the same date of service without the appropriate NCCI modifier (Modifier 25). Modifier 25 must be indicated in the first position of the second billed service. This NCCI change surpasses the Medicaid policy to not bill modifiers on a sick visit when performed on the same date of service as an EPSDT screening/arkids-first B preventative screening. Medicaid policy will be corrected to reflect this change in a provider manual update. Please resubmit the denied claims with the required modifiers along with Modifier 25 in the first modifier position. If you need this material in an alternative format such as large print, please contact the Program Development and Quality Assurance Unit at Thank you for your participation in the Arkansas Medicaid Program. If you have questions regarding these messages, please contact the HP Provider Assistance Center at (toll-free) within Arkansas or locally and out-of-state at (501) Remittance Advices cannot be forwarded. Notify the Arkansas Medicaid Program of any address change, indicating all provider numbers affected by the change. This notification must include the provider s original signature (no facsimiles accepted).

57 Policy Update Notifications Going Paperless in 2016 Added 11/2/15 Effective January 1, 2016, Arkansas Medicaid will end paper mail-outs and begin electronic-only notifications of provider manual updates, official notices, notices of rule making and Remittance Advice messages. To be more fiscally and environmentally responsible, notifications will be sent by , and access to these documents will be available here on the What s New for Arkansas Medicaid Providers webpage. A provider letter and form requesting an updated address was recently mailed. Thank you if you have already responded. If you still need to update your business address (a generic address that more than one person can access), complete the Provider Address Change Form (DMS-673) (Word, new window) and submit it to the Provider Enrollment Unit by mail or fax. Medicaid Provider Enrollment Unit Hewlett Packard Enterprise P.O. Box 8105 Little Rock, AR Fax: (501) When providing your address: Use a generic address that more than one person can access (e.g., xyzclinic@yahoo.com instead of janedoe@yahoo.com). addresses often become outdated when an individual leaves a practice or clinic. You must notify the Division of Medical Services Medicaid Provider Enrollment Unit if any information changes. Make sure the address will accept from hpe.com. You may have to instruct your network administrator or provider to accept s from hpe.com. Arkansas Medicaid sends in bulk and some services block bulk unless instructed otherwise. If Internet access is not yet available in your area, please write no access in the field of the Provider Address Change Form (DMS-673).

58 Provider Address Change Form Provider Name (please print) Provider ID Number/Taxonomy Code Physical Address (Where services are provided) (Post office box allowed ONLY as an addition to a street address) City State ZIP+4 County Phone Number (Include area code) Mailing/Billing Address City State ZIP+4 Phone Number (Include area code) Address Note: Before a change can be made in your provider file, we must have your original signature. A photo copied or stamped signature is unacceptable and the only signature valid for an individual practitioner is their own. Provider s Signature Date Mail this completed form to: Medicaid Provider Enrollment Unit Hewlett Packard Enterprise P.O. Box 8105 Little Rock, AR DMS-673 Rev. 4/07

59 Getting Started - New User 1. Go to learnondemand.org 2. Login 4. Complete Registration Form 5. Select Passwords, Security Questions, and accept Privacy Statement 6. You Are Now a Registered User 7. Search for and Launch Course 8. Complete Course You may exit and resume at any time 9. Logout

60 Claims With Retroactive Eligibility Retroactive eligibility does not constitute an exception to the filing deadline policy. If an appeal or other administrative action delays an eligibility determination, the provider must submit the claim within the 12- month filing deadline. If the claim is denied for recipient ineligibility, the provider may resubmit the claim when the patient becomes eligible for the retroactive date(s) of service. Medicaid may then consider the claim for payment because the provider submitted the initial claim within the 12-month filing deadline and the denial was not the result of an error by the provider. Occasionally the State Medicaid agency or a federal agency, such as the Social Security Administration, is unable to complete a Medicaid eligibility determination in time for service providers to file timely claims. Arkansas Medicaid s claims processing system is unable to accept a claim for services provided to an ineligible individual or to suspend that claim until the individual is retroactively eligible for the claim dates of service. To resolve this dilemma, Arkansas Medicaid considers the pseudo recipient identification number to represent an...error originating within (the) State s claims system. Therefore, a claim containing that number is a clean claim if it contains all other information necessary for correct processing. By defining the initial timely filed claim as a clean claim denied because of agency processing error, we may allow the provider to refile the claim when the government agency completes the eligibility determination. With the claim, the provider must submit proof of the initial filing and a letter or other documentation sufficient to explain that administrative processes (such as determination of SSI eligibility) prevented the resubmittal before the filing deadline. To submit a claim for services provided to a patient who is not yet eligible for Medicaid, enter, on the claim form or on the electronic format, a pseudo Medicaid recipient identification number, Medicaid will deny the claim. Retain the denial or rejection for proof of timely filing if eligibility determination occurs more than 12 months after the date of service. Providers have 12 months from the approval date of the patient s Medicaid eligibility to resubmit a clean claim after filing a pseudo claim. After the 12-month filing deadline (12 months from the Medicaid approval date) claims will be denied for timely filing and will not be paid. It is the responsibility of the provider to verify the eligibility approval date.

61 Medicaid manual verbiage on transferring a beneficiary is provided below Transferring PCP Enrollment PCP Transfers by PCP Request A PCP may request that an individual transfer his or her PCP enrollment to another PCP because the arrangement with that individual is not acceptable to the PCP. A. Examples of unacceptable arrangements include, but are not limited to, the following. 1. The enrollee fails to appear for 2 or more appointments without contacting the PCP before the scheduled appointment time. 2. The enrollee is abusive to the PCP. 3. The enrollee does not comply with the PCP s medical instruction. B. At least 30 days in advance of the effective date of the termination, the PCP must give the enrollee written notice to transfer his or her enrollment to another PCP. 1. The notice must state that the enrollee has 30 days in which to enroll with a different PCP. 2. The PCP must forward a copy to the enrollee and to the local DHS office in the enrollee s county of residence. C. The PCP continues as the enrollee s primary care physician during the 30 days or until the individual transfers to another PCP, whichever comes first. The current approved process for removing patients from a PCP caseload is listed below: Removal must be an acceptable reason to remove beneficiary from the caseload (listed above in manual language). PCP sends a letter to the beneficiary notifying that they have 30 days to find a new PCP. PCP sends a copy of the letter to the local DHS office and fax a copy to their AFMC Outreach Specialist at (Attention: Provider Relations). AFMC sends the information to ConnectCare to ensure that these beneficiaries are removed from the PCP caseload.

62 Process for Deceased Beneficiaries Removal from Caseload PCP will write a letter on clinic letterhead including patient name, Medicaid number, DOB and the date of death. PCP will send this information to their local DHS office and fax a copy to their AFMC Outreach Specialist at (Attention: Provider Relations). The Outreach Specialist will give the information to ConnectCare for removal of the beneficiary from the PCP caseload. It has been confirmed with ConnectCare that a death certificate is not required but the information listed above is needed for the update. Also, a 30 day notice to the beneficiary is not necessary in this situation.

63 Reminder - PCP Assignment Required for Aid Category 06 (Eligibility Expansion) Beginning June 13, recipients who are in Aid Category 06 (Eligibility Expansion) that are served through Medicaid Fee-For-Service will be required to be assigned a PCP before receiving services. This can be accomplished by contacting ConnectCare at or visiting connectcare.arkansas.gov. Please click on Online Services and select Assign/Change Doctor. The 10-digit Medicaid ID number will be required. Updates to the Medicaid Eligibility Strip Beneficiary plan information is now available on the eligibility strip. Please see the options listed below: Standard or Traditional Medicaid Beneficiaries with traditional Medicaid benefit limits (PCP required). Alternative Benefit Plan (ABP) Interim Medicaid Plan determination is being finalized. During this time, the beneficiary will have no limits on physician office visits, labs, or prescriptions (no PCP is required). Alternative Benefit Plan (ABP) Full Medicaid Beneficiary is in the alternative benefit plan and has no limits on prescriptions, labs, or physician office visits (PCP Required). Qualified Health Plan Beneficiary has selected a commercial carrier plan. The carrier name and phone number will be available on the eligibility strip to assist providers with benefits. Please contact your AFMC provider relations representative if you have questions.

64 Breastfeeding is best for both of them. Breastfeeding is best for both of them. can help make it easier. Fewer than one-third of infants born in Arkansas are breastfed six months after birth. 1 The most recent state ranking by the CDC puts us at number 52 in promoting breastfeeding. Breastfeeding is natural but is not always easy. Education and increased support can increase success. Success or failure of breastfeeding promotion efforts can often be traced to the level or lack of administrative support. 2 For more information, the CDC Guide to Breastfeeding Interventions and other resources can be found at Family Doctors and Pediatricians At any prenatal visits and in the hospital, educate mothers about the benefits of breastfeeding and what to expect. Ensure that the hospital staff offers skin-to-skin contact immediately after birth and appropriate support from nurses and/or lactation specialists. At the first post-partum visit: Ask if the mother is still breastfeeding and how it is going. Prescribe vitamin D supplementation for all breastfeeding infants. Assess the infant s weight and address any concerns about whether the baby is getting enough milk. (Any weight loss greater than 7% from birth could be a sign that breastfeeding is not going well.) Ask questions to keep communication open: How often is your baby feeding? How is your milk flowing? Does your baby seem to be latching on well? Remind mothers to eat well and drink plenty of liquids to stay hydrated. If possible, observe the baby feeding to help identify any problems, such as improper or inadequate latch, no swallowing sound, no jaw movement or inability to latch both breasts. can help make it easier. Fewer than one-third of infants born in Arkansas are breastfed six months after birth. 1 The most recent state ranking by the CDC puts us at number 52 in promoting breastfeeding. Breastfeeding is natural but is not always easy. Education and increased support can increase success. Success or failure of breastfeeding promotion efforts can often be traced to the level or lack of administrative support. 2 For more information, the CDC Guide to Breastfeeding Interventions and other resources can be found at Family Doctors and Pediatricians At any prenatal visits and in the hospital, educate mothers about the benefits of breastfeeding and what to expect. Ensure that the hospital staff offers skin-to-skin contact immediately after birth and appropriate support from nurses and/or lactation specialists. At the first post-partum visit: Ask if the mother is still breastfeeding and how it is going. Prescribe vitamin D supplementation for all breastfeeding infants. Assess the infant s weight and address any concerns about whether the baby is getting enough milk. (Any weight loss greater than 7% from birth could be a sign that breastfeeding is not going well.) Ask questions to keep communication open: How often is your baby feeding? How is your milk flowing? Does your baby seem to be latching on well? Remind mothers to eat well and drink plenty of liquids to stay hydrated. If possible, observe the baby feeding to help identify any problems, such as improper or inadequate latch, no swallowing sound, no jaw movement or inability to latch both breasts.

65 At the hospital Hospitals have a critical role in encouraging breastfeeding and increasing long-term success. Though nurses and lactation specialists provide most of the hands-on support, physicians and administrators must set policy and ensure that staff members have the training and resources needed. The UNICEF/WHO Baby Friendly Hospital Initiative ( is now being implemented at hospitals across the United States. The BFHI Ten Steps to Successful Breastfeeding for U.S. hospitals are: ➊ Have a written breastfeeding policy that is routinely communicated to all health care staff. ➋ Train all health care staff in skills necessary to implement this policy. ➌ Inform all pregnant women about the benefits and management of breastfeeding. ➍ Help mothers initiate breastfeeding within one hour of birth. ➎ Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants. ➏ Give newborn infants no food or drink other than breastmilk, unless medically indicated. ➐ Practice rooming in allow mothers and infants to remain together 24 hours a day. ➑ Encourage breastfeeding on demand. ➒ Give no pacifiers or artificial nipples to breastfeeding infants. ➓ Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. To be designated by Baby-Friendly USA, hospitals must comply with the International Code of Marketing of Breast Milk Substitutes ( Hospitals should also ensure that HIV status is known at labor and that all maternal medications are compatible with breastfeeding. During discharge, ensure that the baby is scheduled for routine pediatric care within the first week. 1. Breastfeeding Report Card, United States 2010: Outcome Indicators, based on the United States National Immunization Survey, 2007 Births. Centers for Disease Control and Prevention, Department of Health and Human Services. Available at 2. Int J Gynaecol Obstet. 1990;31 Suppl 1:61-5; discussion Available at Make mothers aware of any resources available, such as the Arkansas Breastfeeding Helpline ( ). At the hospital Hospitals have a critical role in encouraging breastfeeding and increasing long-term success. Though nurses and lactation specialists provide most of the hands-on support, physicians and administrators must set policy and ensure that staff members have the training and resources needed. The UNICEF/WHO Baby Friendly Hospital Initiative ( is now being implemented at hospitals across the United States. The BFHI Ten Steps to Successful Breastfeeding for U.S. hospitals are: ➊ Have a written breastfeeding policy that is routinely communicated to all health care staff. ➋ Train all health care staff in skills necessary to implement this policy. ➌ Inform all pregnant women about the benefits and management of breastfeeding. ➍ Help mothers initiate breastfeeding within one hour of birth. ➎ Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants. ➏ Give newborn infants no food or drink other than breastmilk, unless medically indicated. ➐ Practice rooming in allow mothers and infants to remain together 24 hours a day. ➑ Encourage breastfeeding on demand. ➒ Give no pacifiers or artificial nipples to breastfeeding infants. ➓ Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. To be designated by Baby-Friendly USA, hospitals must comply with the International Code of Marketing of Breast Milk Substitutes ( Hospitals should also ensure that HIV status is known at labor and that all maternal medications are compatible with breastfeeding. During discharge, ensure that the baby is scheduled for routine pediatric care within the first week. 1. Breastfeeding Report Card, United States 2010: Outcome Indicators, based on the United States National Immunization Survey, 2007 Births. Centers for Disease Control and Prevention, Department of Health and Human Services. Available at 2. Int J Gynaecol Obstet. 1990;31 Suppl 1:61-5; discussion Available at Make mothers aware of any resources available, such as the Arkansas Breastfeeding Helpline ( ). This material was prepared by the Arkansas Foundation for Medical Care Inc. (AFMC) under contract with the Arkansas Department of Human Services, Division of Medical Services. The contents presented do not necessarily reflect Arkansas DHS policy. The Arkansas Department of Human Services is in compliance with Titles VI and VII of the Civil Rights Act. QP2-BFP.CAR, 1-3/11 This material was prepared by the Arkansas Foundation for Medical Care Inc. (AFMC) under contract with the Arkansas Department of Human Services, Division of Medical Services. The contents presented do not necessarily reflect Arkansas DHS policy. The Arkansas Department of Human Services is in compliance with Titles VI and VII of the Civil Rights Act. QP2-BFP.CAR, 1-3/11

66 Cervical Cancer Screening Guidelines Summary WHAT S NEW INITIAL SCREENING All women should begin cervical cancer screening at age 21. Women under the age of 21 should NOT be screened regardless of their age of first sexual contact unless they have a high-risk condition, such as HIV. WOMEN AGES Women of this age should receive cervical cancer screening once every 3 years using either a conventional pap smear or a liquid-based cytology method. HPV testing should not be performed for the purpose of screening in this age range. WOMEN AGES Women of this age should receive co-testing for cervical cancer screening. Co-testing combines cytology (conventional or liquid based) with HPV testing. The recommended screening interval is every five years. Cytology (conventional or liquid based) without HPV testing is also acceptable for screening of women in this age group, but should be done every three years. WOMEN AGES 65 YEARS AND OLDER Women of this age should not be screened if they have had adequate prior screening and no history of CIN or cervical cancer within the last 20 years. Hysterectomy: Women who have had a hysterectomy with removal of the cervix for benign reasons and with no history of abnormal or cancerous cell growth may discontinue routine cervical cancer screening. Women who have had a hysterectomy who have had previous cervical cancer or CIN should continue to receive individualized testing. More frequent or earlier (under age 21) cervical cancer screening may be indicated for high-risk women, such as patients with HIV, patients who are immunosuppressed or patients who were exposed to DES in utero. Testing should be individualized. HPV Vaccine: An HPV vaccine is recommended for all girls, ages The CDC states that girls as young as nine years of age may receive the vaccine; however, the provider should be aware that insurance plans may not cover the vaccine in 9-11-year-old patients. Ideally, the vaccine should be administered to girls before they reach an age when they might be exposed to HPV. The HPV vaccine is not recommended for pregnant women. At this time, cervical cancer screening is the best approach to prevent cervical cancer. Recommendations for cervical cancer screening apply regardless of the patient s HPV vaccination status.

67 CERVICAL CANCER SCREENING GUIDELINES SUMMARY Pap collection procedure PAP COLLECTION PROCEDURE Cytology specimens should be collected using a broom or a brush-spatula technique. If using a broom device with a liquid-based method, follow the manufacturer s specifications. If using a brush-spatula technique, an extended tip spatula is recommended. The brush should be inserted in to the endocervix first and rotated one-half turn. The cells should be applied to a glass slide and spray-fixed immediately. Repeat the procedure with the extended-tip spatula. Avoid excessive force as this may produce bleeding, which may obscure the specimen. A single slide may be used at the discretion of the clinician rather than using two slides. A Pap smear that is performed on a pregnant patient uses the same technique except that some clinicians may prefer to use a Dacron swab instead of an endocervical brush. REMINDER These recommendations apply only to screening situations; that is, for patients who have no current evidence or history of CIN or cervical cancer. Please refer to other guidelines for follow-up and testing of patients who have had abnormal cytologic screening, positive HPV testing or a diagnosis of CIN or cervical cancer. PLEASE NOTE Cervical cancer screening should not be used as a substitute test for other sexually transmitted diseases. However, specimens collected using liquid-based techniques may also be tested for HPV, gonorrhea and chlamydia by some laboratories. SOURCE: org/cgi/content/short/52/6/342 THIS MATERIAL WAS PREPARED BY THE ARKANSAS FOUNDATION FOR MEDICAL CARE INC. (AFMC), THE MEDICARE QUALITY IMPROVEMENT ORGANIZATION FOR ARKANSAS, UNDER CONTRACT THE ARKANSAS DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL SERVICES. THE CONTENTS PRESENTED DO NOT NECESSARILY REFLECT ARKANSAS DHS POLICIES. THE ARKANSAS DEPARTMENT OF HUMAN SERVICES IS IN COMPLIANCE WITH TITLES VI AND VII OF THE CIVIL RIGHTS ACT. QB2-CC.FLY,1-3/13