Your Rights When You Appeal

We appeared live on Facebook with Managing Attorney Thomas Nichols from Disability Rights Arkansas to answer your questions and discuss your rights when appealing a Medicaid decision. Watch because this video is full of helpful information from beginning to end!

Thomas refers to a presentation with more information on appeals that you might want to view.

When filing an appeal, you have resources in the state to help you. Even if you can’t afford it, you can find quality lawyers or law advice. Make sure to contact:

Also, we reference Rights that we listed in a previous post. Make sure to read it.

What if you don’t agree with your Assessment results?

Even though many people may not need to appeal, several of you have asked before about how to appeal your Independent Assessment if you aren’t satisfied with your tier placement. We asked DHS for the appeal policy.

Watch for more resources on how to appeal, tips, and what your rights are!

DHS says that below is the information that you will receive with your Independent Assessment results packet.  Each person will receive this notice after his/her IA has been scored.  These results packets began going out Friday.  Some individuals began receiving PASSE services prior to the receipt of their results packets. 

 If you do not agree with your assessment results:

You, your representative, and your provider have the right to request a hearing.

Requirements for the request:
  1. the request must be received at the DHS Office of Appeals and Hearings’ address below no later than (date calculated from notice mailing date [35 days + mailing date])
  2. Please put your request for a hearing and for any services in writing. With your request, please include a

copy of this letter and mail it to:
Arkansas Department of Human Services
Office of Appeals & Hearings
P.O. Box 1437, Slot N401
Little Rock, AR 72203
Division of Medical Services

If you ask for a hearing, these are your rights, per DHS:

  • You may go to the hearing
  • You may be represented by a lawyer or any other person you choose
  • Before the hearing, you have the right to see your record and any other evidence to be used at the hearing
  • You have the right to present your own evidence
  • You have the right to bring your own witnesses
  • You have the right to question any witness against you
  • You have the right to request, if applicable, certain current services continue “as is” pending an appeal decision if your request is received at the Office of Appeals and Hearings’ address listed above by (date calculated from notice mailing date [15 days + mailing date])

You may be able to get free legal aid.

If you need legal help, DHS sends these recommendations:

 DHS also recommended the following link might be helpful to review:  http://humanservices.arkansas.gov/images/uploads/occ/DHSPolicy1098.pdf to understand the process.

Watch for more resources on how to appeal, tips, and what your rights are!

MSL has attended presentations by other community resources such as Disabily Rights Arkansas who have explained in more detail what to put in your letter and tips you might need. One very important thing to do is MAKE SURE TO KEEP EVERYTHING MAILED TO YOU AS WELL AS ALL ASSESSMENTS OR THINGS THAT COULD BE USED AT THE HEARING. We will be collaborating with these other organizations to release more resources as soon as we can!

 

One Therapy Rule – Part 1

MSL has done some research on a change coming our way. You may have heard of it – the “One Therapy Rule,” formally known as the EIDT Program. Watch this video and stay tuned for your opportunity to take action.

Live Q&A with DHS about PASSEs

MSL took your questions to DHS, and they answered live on Facebook. This video has several good demonstrations and answers that you might need to see. The PASSEs will start taking clients in February 2018.

Watch the video:

Tax Reform Bill: How to Contact AR Senators


Watch the video above to get all of the contact information to get contact information and tips.

Other helpful links:

https://www.npr.org/templates/event/embeddedVideo.php?storyId=567758536&mediaId=567762951

Are you thankful for Medicaid?

Author: Lainey Morrow, Medicaid Saves Lives’ Founder

It’s customary this time of year to count our blessings, and there’s one in particular that millions of Americans shouldn’t forget: Medicaid. 

If you’re a recipient (or know a recipient), think for a second what your life would be like without Medicaid.

My little girl qualifies for TEFRA because of her diagnosis, and she’s thriving because Medicaid gives her treatments like therapy and medicines that we simply can’t afford. Medicaid not only helps her day-to-day, but it’s also giving her a future where she may someday be able to live on her own and provide for herself. Because of Medicaid, she can climb stairs, say that she wants a drink, draw a line, feed herself with a spoon, and sit quietly with other students around a table. When I think of life without Medicaid, I see many who would be crushed under personal debt and suffering without hope.

If you’re thankful for Medicaid, please tell those who make our state and national policies, especially if you need to continue receiving it.

This is the perfect time of year to let our lawmakers know that we’re thankful for Medicaid. Why? Because it’s improving and even saving lives! I ask you to take a moment, and write your elected officials a note. Even better, include a photo. Tell them why Medicaid is important to you. If writing several is overwhelming, just start with one. 

You can also post on social media about why Medicaid is important to you using the hashtag #thankful4Medicaid to help others see why Medicaid is so important.

We need to tell everyone the great things that Medicaid does and who it helps. People need to hear this positive message. By sending notes, calling, and posting on social media, we are clearly communicating that we still need Medicaid, and we’re directly asking the people in charge to continue funding Medicaid for us.

Let’s flood our government with letters and calls this holiday season!

Arkansas Only

Contact any elected official in the US!

Understanding the House Tax Bill

Taxes affect our daily lives, and the House is working on a bill to “reform the tax code.” If taxes are drastically altered, it won’t just affect our personal taxes; Medicaid funding could be affected as well. For example, Senator Cotton called for the repeal of the Obamacare individual mandate through tax reform. That’s why it’s so important to stay on top of what’s happening.

A House committee released the bill, the “Tax Cuts and Jobs Act,” this afternoon, and it’s a very long read. 

This is just a first version. They will revise the bill and try to pass it through the House by Thanksgiving to send to the Senate in order for it to take affect by January 1, 2018. 

Take the time to try to understand it and respond if necessary. Here are a few articles to help you understand what’s going on:

Make sure you understand this for yourself, and contact your U.S. Senators with your questions, concerns, and comments!

    Therapy Cap PA Requests: Q & A 


    The PT, OT, and SH Association Presidents regularly meet with DHS and AFMC to discuss issues that providers have when requesting Prior Authorizations (PAs) for children who need therapy over the 90-minute cap. These are the results of their latest meeting.

    Keep track of your questions and email them to be discussed at the next meeting.


    The Recap of ArkSHA, ArPTA, and AROTA meeting with AFMC and DDS on 08-25-17:

    The following are issues raised by members of ArkSHA, ArPTA and AROTA, and responses from AFMC and DDS.

    Issue: Shifting of Units Between Therapist and Assistant

    There are still questions regarding the length of time it is taking to shift units from PT/OT/ST to PTA/COTA/SLPA and vice versa. AFMC reports that following completion of the large number of DMS-640 form validations AFMC received many change requests to prior authorizations. AFMC encouraged their staff to continue to process initial DMS-640 validations and that all changes would need to be checked before processing. Currently, AFMC states that they are about 10 days out on corrections and Jarrod McClain, AFMC Director for Clinical Review, indicated that their staff are working diligently to get the updates made as quickly as possible. The updates to the PA’s flow to DXC each night and providers can start billing immediately upon receipt of the changes.

    In addition, Jarrod stated that AFMC is working to decrease the timeframe for corrections but they have to ensure that they are getting the correct request ID modified. According to Jarrod, it takes a few days to check and update the claims data extract file. If providers continue to see a delay, please contact Jarrod McClain at AFMC. He will personally see that his staff checks on the status of their request and get it processed.

    Issue: Use of evaluations from preschool programs to kindergarten

    There was concern from many members as to how long their evaluations will be valid in a schools setting. The consensus is that if the evaluation utilized is an evaluation conducted by a non-educational agency, or by a provider who is not contracted by an educational agency, then the evaluation is good for one year. If an educational agency or a contractor of the educational agency conducted the evaluation, then the evaluation falls under the school-based evaluation criteria of every 3 years.

    Issue: Some prior authorizations were only approved after sending in a cover sheet restating information included in the evaluation.

    AFMC was aware of this issue and is working to improve their processes for approval. In the meantime, providers are encouraged to highlight justification for medical necessity in the evaluative reports, including statements about how the services recommended are under accepted standards of practice to treat the patient’s condition, how services are complex and will require the skilled services of a qualified therapist, and a statement about therapy prognosis (See Medicaid Manual Section II). Though a cover letter outlining these justifications is not required, providers are encouraged to consider using a cover letter attached to the evaluation to make these medical necessity statements more salient for reviewers.

    Issue: Are reviewers actually reading the evaluations or just looking for technical language?

    AFMC assured us that they are reading all evaluations. They perform both technical and administrative reviews in order to ensure that all requirements of the evaluative reports are included, as well as a medical necessity review to ensure that justification for medically based services is included.

    Issue: I heard that AFMC was using nurse reviewers and not experienced pediatric therapists in each discipline. Is this true?

    AFMC utilizes registered nurses to perform the initial reviews of all PA requests. If a request is denied than the request is assessed by an experienced licensed therapists specific to the discipline. If the therapist agrees with the denial it is then sent to a board certified pediatric physician for final review. If a provider does not agree with the denial or would like to request reconsideration they may do so by resubmitting the request.

    Issue: What about beneficiaries who receive services from multiple providers for the same service?

    AFMC and DDS continue to emphasize the need for care coordination for beneficiaries with multiple providers of the same modality (physical, occupational or speech therapy). Dr. Chad Rodgers, AFMC Medical Director, attended our meeting and reported that the pediatricians and PCPs he has been in contact with are interested in understanding what situations justify the appropriate signing off on multiple prescriptions. He asserts that although he can’t speak for all physicians he personally looks at every request for therapy services before signing them. He recognized that it is difficult to for most physicians to understand why a child needs multiple services. He and assistant director of DDS Elizabeth Pittman stated that it would be beneficial to state on the DMS-640 the specific need for a particular service and that the beneficiary will need the services of multiple therapists. AFMC and DDS are considering a change to the DMS-640 forms in the future to accommodate the different services provided within one discipline. Elizabeth Pittman reported that the new MMIS system (which has an anticipated implementation of summer of 2018) will be less burdensome on providers and will have the ability to disclose is the beneficiary is receiving services from other providers. Until then, providers need to ask during the intake process if the recipient is receiving therapy services from any other provider, and then coordinate as needed. According to Jarrod McClain, only 10 providers have bumped into challenges with the multiple provider issues thus far.

    Issue: For short term scripts (i.e. ortho docs who write for 2-6 weeks) that then need an extension once the patient has had a follow-up recheck. What is the most efficient way to keep PA’s from having to be unnecessarily done?

    Providers can simply go into Review Point, and click the extend button. The codes will be transferred over and the new prescription can be uploaded. Information about the progress of the patient and continued medical necessity should be included with the extension.

    Issue: It has come to the attention of AFMC and DDS that some facilities are sending notices to parents that they should not allow services for their child in the school due to the need for a PA if the school and independent facility are both treating the beneficiary.

    Although Medicaid is a “medical” assistance program, it recognizes the importance of school-based services. The federal Medicaid program actually encourages states to use funds from their Medicaid program to help pay for certain healthcare services that are delivered in the schools, providing that federal regulations are followed. The associations stand with AFMC and DDS that sending notices to parents regarding billing for services between schools and independent clinics is not recommended. IDEA laws require schools to provide services to beneficiaries if needed for educational purposes. Schools also must provide therapy that is medically necessary. Therapy services outside of the school setting should not replicate services provided by therapists contracted or working with the school.

    Issue: A representative at DHS has stated that physical therapy re-eval codes are no longer a valid code as of July 1st. Has anything changed in the recent rule change?

    Reevaluation codes are not currently and haven’t been a reimbursable code. The two billable codes for physical therapy services are 97001 and 97110.

    Solution to Denied PAs for Therapy Providers

    MSL has been made aware that there’s a lot of confusion on submitting PAs to request more than 90 minutes of therapy for children since the therapy cap was implemented on July 1, 2017. Lainey has talked with AFMC and DHS as well as the OT Association President who has been successful in submissions.


    You need a separate statement letter that answers the following questions individual to the child’s case:

    1. How does the therapy administered effectively treat the beneficiary’s condition?

    2. What gives you a reasonable expectation that the beneficiary is experiencing meaningful improvement or that the therapy is preventing worsening of the beneficiary’s current condition?

    3. How are the frequency, intensity, and duration of the requested therapy services realistic for the age of the child?

    List the question and provide the answer. Make sure you provide the other information listed there as well. AFMC told Lainey today that they will deny any submission that does not have this requirement. If you have received denial with 3 statements that say you didn’t meet the requirement, try resubmitting with this.