Prior Authorization Review Process

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Follow these five steps when submitting a Prior Authorization Review:

Step 1

Prior authorization requests are initially screened by a Review Coordinator (a registered nurse) to determine if sufficient documentation is present to complete the medical necessity review. If the prior authorization request form is incomplete, the Review Coordinator notifies the provider in writing that additional information is needed to complete the review.

Step2

If the documentation submitted along with the prior authorization request does not establish medical necessity of the requested services, or if the Review Coordinator questions any of the documentation, the prior authorization packet is referred to a Physician Advisor for determination.

Step 3

The Physician Advisor utilizes his/her medical judgment, in accordance with the established Medicaid policies, to review medical necessity of the requested services.

Step 4

If the Physician Advisor denies any service, or approves any service at a reduced level, letters are mailed to the recipient and the Medicaid provider notifying them of the review determination.

Step 5

Providers have thirty (30) calendar days from the date of the denial letter to request a reconsideration of the review determination on any prior authorization request that is denied or approved at a reduced level. To do so, the provider must submit to QSource a written request for reconsideration, a copy of the denial letter, and additional information to support overturning the denial.

Recipients and providers may request an appeal of the review determination through the Office of Appeals and Hearings.

Contact us at:
QSource of Arkansas
124 West Capitol Avenue, Suite 900
Little Rock, AR 72201
1-866-321-5415

Or email us!