Providing Quality Care
As our valued provider, the way you serve our members is important. Arkansas Total Care is here to help you provide the very best care. This information is part of our Quality Improvement (QI) Program, which was made to address the quality and safety of services given to our members.
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is a chance for your patients to tell us how they feel about their care, including their experience with their providers and health plan. CAHPS scores are public and can help determine if patients and members should stay with their provider or health plan or look elsewhere for their care. Surveys are sent to our members from February through June of each year.
You are key to providing the best care to our members. Your happiness is important to us too. We assess your experience with the health plan through a yearly Provider Satisfaction Survey (PSS). Arkansas Total Care reviews the PSS and uses it to improve the provider experience. Please be sure to take the survey if you are sent one.
During the credentialing process, Arkansas Total Care gathers information from various sources to assess your application. Having accurate information is key, so please review and send us any corrections as soon as possible. You have the right to review the status of your credentialing or recredentialing application at any time by calling your Provider Engagement Representative.
If your address or phone number changes, or if you can no longer accept new patients or are leaving the network, please let Arkansas Total Care know as soon as possible so we can update our Provider Directory. Having access to provider information is important to our members, and we want to work with you to ensure Continuity of Care.
Utilization Management (UM) decisions are based on the Appropriateness of Care and Service, and the Existence of Coverage.
Arkansas Total Care does not reward providers, practitioners or others for issuing Denials of Coverage. We do not have financial incentives that encourage choices resulting in underutilization. Denials are based on Lack of Medical Necessity or Covered Benefit. Nationally recognized criteria (such as InterQual or MCG) are used, if possible, for service requests, with added criteria developed internally.
Submitting full clinical details with the request for a service or treatment will help us make apt and timely UM decisions. You may talk about UM denial decisions with a physician or other reviewer at the time of Notification of an Adverse Determination. You may also ask for UM criteria related to an authorization request, or for any other UM-related issue by reaching out to the UM Department at the health plan.
Making sure our members get the best care includes helping adolescents move to an adult care provider. If you or one of your patients need help finding an adult care provider or specialist, contact Arkansas Total Care or refer to your Provider Manual. We can help find an in-network adult care provider or arrange care, if needed.
The Health Plan Formulary/Preferred Drug List (PDL) is based on plan benefits and is updated on a routine basis. Arkansas Total Care uses the Arkansas Medicaid Preferred Drug List. A link to the current PDL, which includes details about covered drugs, restrictions, Prior Authorization Requirements, etc., can be found on the health plan website.
Our Care Management team is here for members who may benefit from more Coordination of Services. The team can help providers with member issues, such as Non-Adherence to Medication/Medical Advice, Multiple Complex Comorbidities, or to offer guidance with a new diagnosis.
The Care Management team helps members:
- Reach the best health, functionality, and quality of life through disease or condition management.
- Determine and access benefits and resources.
- Create goals and work with family, providers, and community organizations to meet those goals.
- Ensure timely receipt of services in the right setting.
Early intervention is key to making the most of treatment options and reducing complications related to illness, injury, or chronic condition. Members can get care through face-to-face visits, over the phone, or in a provider’s office. You can refer members to the Care Management Program at any time by calling the health plan or submitting a referral through the Provider Portal.
Every year, Arkansas Total Care reviews Appointment Availability for primary care providers, specialists, and behavioral health practitioners. There are standards in place for each type of appointment and provider. Please refer to the Provider Manual for how soon our members should be able to get an appointment.
Providers are expected to follow members' rights. Members are informed of their Rights and Responsibilities in their Member Handbook.
Member rights include:
- Getting all services the health plan provides.
- Being treated with dignity and respect.
- Knowing their medical records will be kept private and in line with state laws, federal laws, and health plan policies.
- Being able to see their medical records.
- Being able to get information in a different format in line with the Americans with Disabilities Act (ADA).
Member responsibilities include:
- Knowing their health problems and telling their provider if they do not understand their treatment plan.
- Keeping scheduled appointments and calling the provider’s office if there is a delay or cancellation.
- Showing their member ID card at appointments.
- Following the treatment plans and instructions for care that they have agreed to.
Please refer to the Provider Manual for the full list of Rights and Responsibilities.
Arkansas Total Care is pleased to take part in the Choosing Wisely® Initiative. The American Board of Internal Medicine (ABIM) urges providers and patients to “Choose Wisely.” The Choosing Wisely Initiative seeks to advance a national dialogue on avoiding unneeded medical tests, treatments, and procedures.
Please visit choosingwisely.org to find resources for your patients and clinicians to promote shared decision-making.