(a) A provider seeking service authorization
must make a request electronically or in writing on a certificate of medical
necessity.
(b) Service
authorization is required for
(1) the rental
of durable medical equipment, medical supplies, prefabricated off-the-shelf
orthotics, or related items and services under
7
AAC 120.200(a)(2) that is indicated
as requiring service authorization in the
Alaska Medicaid DMEPOS Fee
Schedule, Tables 1-5 through 1-9, adopted by reference in
7
AAC 160.900;
(2) medical supplies that exceed the maximum
units or a 30-day limit set by the department;
(3) customized or optimally configured
durable medical equipment, medical supplies, prefabricated off-the-shelf
orthotics, or related items and services under
7
AAC 120.200(a)(2);
(4) items that are listed as requiring
service authorization on the
Alaska Medicaid DMEPOS Fee Schedule,
Tables 1-5 through 1-9, adopted by reference in
7
AAC 160.900 or the Alaska Medicaid DMEPOS Interim Fee
Schedule;
(5) items that are
identified as miscellaneous in the United States Department of Health and Human
Services, Centers for Medicare and Medicaid Services (CMS)
Healthcare
Common Procedure Coding System (HCPCS), adopted by reference in
7
AAC 160.900;
(6) respiratory therapy assessment visits for
ventilator-dependent recipients;
(7) home infusion therapy;
(8) enteral and oral nutritional
products;
(9) the purchase of
durable medical equipment, medical supplies, prefabricated off-the-shelf
orthotics, or related items and services under
7
AAC 120.200(a)(2) for a recipient in
a skilled nursing facility or intermediate care facility;
(10) continuous oxygen for a recipient in a
skilled nursing facility or an intermediate care facility;
(11) the purchase of durable medical
equipment, medical supplies, prefabricated off-the-shelf orthotics, or related
items and services under
7
AAC 120.200(a)(2) if the charge to
the department exceeds $1,000;
(12)
medical supplies and services for a single claim or for a 30-day supply if the
charge to the department exceeds $1,000;
(13) durable medical equipment, medical
supplies, prefabricated off-the-shelf orthotics, or related items and services
under 7 AAC
120.200(a)(2) requiring CMS prior
authorization under 42
C.F.R.
414.234(c)(1);
(14) Medicare-covered durable medical
equipment, medical supplies, prefabricated off-the-shelf orthotics, or related
items and services under
7
AAC 120.200(a)(2) that are for a
recipient who is eligible under both Medicare and Medicaid, and that Medicare
(A) has determined medically unnecessary for
that recipient; or
(B) has denied
after finding that a provider sought payment in excess of copay and
deductible;
(15)
optimally configured power wheelchairs that require payment under capped rental
rules provided where the provider of durable medical equipment, medical
supplies, prefabricated off-the-shelf orthotics, or related items and services
under 7 AAC
120.200(a)(2) requests direct
purchase; and
(16) items that are
medically necessary to be replaced before the qualified replacement time, even
if they had not initially been identified as requiring service
authorization.
(c) A
request for service authorization must be consistent with Medicare requirements
where applicable and must also include
(1) a
prescription order with a certificate of medical necessity completed by the
enrolled ordering
(B) physician assistant; or
(C) advanced practice registered
nurse;
(2) if the
recipient is under 21 years of age, documentation by the person under (1) of
this subsection that the item or service is necessary to treat, correct, or
ameliorate a defect, condition, or physical or mental illness; the
documentation may replace the certificate of medical necessity required under
(1) of this subsection
(3) for
requests under (b)(2) and (4) of this section relating to a request for
incontinence supplies, the certificate of medical necessity required under (1)
of this subsection, on a form provided by the department, that includes the
(A) diagnosis, including the diagnosis code
from the
International Classification of Disease, adopted by
reference in
7
AAC 160.900, that is related to the cause or is
causing the incontinence of the bladder, bowels, or both;
(B) diagnosis, including the diagnosis code
from the
International Classification of Disease, adopted by
reference in
7
AAC 160.900, of the type of incontinence;
(C) for recipients at least three years of
age and under 10 years of age, documentation that the recipient has not
responded to, would not benefit from, or has failed bowel or bladder
training;
(D) prognosis for
controlling incontinence;
(E) name
of each item to be dispensed;
(F)
frequency of incontinence;
(H) diuretic or
other medications that increase output;
(I) products currently being used;
(J) skin integrity, including vulnerability
to skin breakdown;
(K)
measurements of product sizes;
(L)
quantity of each item medically necessary;
(M) known allergies to product materials; and
(N) description of ability to
manage incontinence independently or with assistance.
(d) In addition to the
requirements of (c) of this section, a service authorization request for the
following items must, if available, include the manufacturer information, item
description or number, global trade item number (GTIN), suggested list price,
and serial number:
(1) items that are
identified as miscellaneous in the
Healthcare Common Procedure Coding
System (HCPCS), adopted by reference in
7
AAC 160.900;
(2) customized or optimally configured
durable medical equipment; and
(3)
items listed in (c)(3) of this section; a service authorization request for
those items must also include the product code and national drug code (NDC),
when applicable.
The certificate of medical necessity form referred to in
7 AAC 120.210(a) and (c) may be obtained from the Department of Health and
Social Services, Division of Health Care Services, 4501 Business Park
Boulevard, Suite 24, Anchorage, Alaska 99503-7167.
The United States Food and Drug Administration, Center
for Drug Evaluation and Research's national drug code directory referred to in
7 AAC 120.210(d) is available at the following Internet address:
https://www.fda.gov/Drugs/lnforinationOnDrugs/ucml42438.htin
The department's Alaska Medicaid DMEPOS Interim Fee
Schedule, referenced in 7 AAC 145.210(b), may be obtained from the Department
of Health and Social Services, Division of Health Care Services, 4501 Business
Park Boulevard, Building L, Anchorage, Alaska 99503-7167, or at
http://www.medicaidalaska.com/providers/FeeSchedule.asp.
