Current through November 28, 2024
(a) To be eligible
for payment under 7 AAC 105 - 7 AAC 160 for providing prosthetics, orthotics,
and related items and supplies, a provider must
(1) have and maintain a valid business
license issued under AS 43.70 and 12 AAC 12;
(2) be enrolled under
7
AAC 105.210 as a prosthetics and orthotics provider,
if the provider provides prosthetics and customized orthotic devices and
services;
(3) maintain continuous
accreditation or certification by the American Board for Certification in
Orthotics, Prosthetics, and Pedorthics, the Board for Orthotist/Prosthetist
Certification, the National Examining Board of Ocularists, Inc., or other
similar certifying or accrediting agency approved by the department
demonstrating applicable professional standards and qualifications;
(4) continuously employ at least one
individual who maintains the credentials of Certified Orthotist, Certified
Prosthetist, Certified Prosthetist/Orthotist, or Certified Pedorthist and who
is in-charge; in this paragraph, "in-charge" means that the individual has the
authority and responsibility for the facility's compliance with practice
standards at the enrolled provider location;
(5) provide to the department evidence at
initial enrollment and upon request that the provider is enrolled as a Medicare
provider and Medicare enrollment is maintained concurrent with Medicaid
enrollment; and
(6) notify the
department in writing not later than 30 days after a change in status of any of
the requirements of this subsection; the department may sanction or disenroll
under 7 AAC 105.400 -
7
AAC 105.490 a provider for failing to continuously
meet the requirements of enrollment under this section.
(b) Subject to the applicable provisions of
7
AAC 120.300 -
7
AAC 120.399, a provider enrolled under
7
AAC 105.210 as a prosthetics and orthotics provider
may request payment for prosthetic or orthotic devices and services furnished
to a recipient, if the item or service is
(1)
prescribed by a physician, physician assistant, or advanced practice registered
nurse who is enrolled in accordance with
7
AAC 105.210 and acting within the scope of that
person's license;
(2) appropriate
for use in the recipient's home or community;
(3) not provided by, or under arrangements
made by, a home health agency; and
(4) dispensed in compliance with a valid
prescription order from an individual under (1) of this subsection; if a
current prosthesis needs to be repaired or modified, each of the following must
be met:
(A) all applicable warranties are
expired;
(B) the cost of the repair
or modification is less than 50 percent of the cost of a new prosthesis and the
provider has submitted supporting documentation; and
(C) the repair has a minimum 30-day
warranty.
(c)
A prosthetics and orthotics provider shall
(1)
ensure that the recipient is eligible to receive the product;
(2) maintain proof of receipt for items
supplied to recipients consistent with
7
AAC 105.230 and submit the proof of receipt to the
department upon request; and
(3)
accept the return of a substandard item.
(d) Due to the complexity of the information
required for prosthetics and custom fabricated orthotics, a certificate of
medical necessity may be prepared by the prosthetics and orthotics provider if
(1) the prosthetic or custom fabricated
orthotic is prescribed by the recipient's physician, physician assistant, or
advanced practice registered nurse before the completion of the certificate of
medical necessity by the prosthetics and orthotics provider;
(2) the certificate of medical necessity is
reviewed and signed by the recipient's prescribing physician, physician
assistant, or advanced practice registered nurse, acknowledging concurrence
with the treatment plan; and
(3)
documentation of the certificate of medical necessity is maintained in the
recipient's medical record by the recipient's prescribing physician, physician
assistant, or advanced practice registered nurse.
(e) A prescription order for a prosthetic or
orthotic device or service must contain the
(1) recipient's name and date of
birth;
(2) item or service being
prescribed;
(4) international
classification of disease code;
(5)
quantity of the item or service being prescribed;
(6) duration or estimated length of need for
the item; and
(7) enrolled
prescribing physician, physician assistant, or advanced practice registered
nurse's signature and order signature date;
(f) A prescription order for a prosthetic or
orthotic device or service may be part of the certificate of medical necessity,
if the certificate of medical necessity includes all of the components of a
prescription order as described in (e) of this section.
(g) A prescription order for a prosthetic or
orthotic device or service, including a certificate of medical necessity
serving as a prescription order, will be accepted for not more than one year
from the signature date. A backdated order will not be accepted as
authorization for an item supplied before the provider receiving a valid
prescription order for the item. A retrospective start date for a prescription
order, with current day signature, may be considered for service authorization
review under
7
AAC 120.210 upon individual medical necessity and if
all other state and federal regulatory provisions are met. If a retrospective
start date is permitted, the prescription order only be valid for one year from
the retrospective start date.
(h)
The prescribing physician, physician assistant, or advanced practice registered
nurse's hard-copy original or authenticated digital signature must be affixed
to the prescription order or the certificate of medical necessity serving as a
prescription order. The department will not accept a signature stamp or a copy
of a signature as part of a valid prescription order even if affixed to the
prescription order by the prescriber. A prescription order or certificate of
medical necessity received by means of facsimile, with the prescriber's
signature, may be accepted.
(i) A
prosthetics and orthotics provider enrolled under this section may request
payment, as follows, for the reasonable direct costs of delivering or shipping
prosthetics or orthotics incurred by the dispensing provider when using the
most cost-effective means:
(1) to be eligible
for payment, the following conditions apply:
(A) the recipient resides outside the
municipality where the business of the enrolled dispensing provider is
located;
(B) the item or service is
unavailable from a provider of prosthetics and orthotics enrolled under this
section in the municipality in which the recipient resides; and
(C) the item shipping from the manufacturer
to the provider is durable medical equipment, prosthetics, orthotics, or unique
or specialized replacement parts and for which the final unaltered purchase
invoice price exceeds $250;
(2) if the shipping charge submitted by the
provider exceeds $50, the claim and supporting documents must include
(A) the recipient's name;
(B) the address the item was shipped or
delivered to;
(C) an itemized list
of the products included in the shipment or delivery, to include product name,
product identifier, quantity, and serial number, when applicable;
(D) the shipment and delivery date;
(E) the recipient's signature with date of
receipt; and
(F) the total charges
minus all discounts, substantiated by a paid shipping invoice reflecting the
actual payment.
(j) The department will not pay separately
for the costs of administrative expenses related to the provision of
prosthetics and orthotics. The following costs are considered administrative
expenses and are included in the payment for prosthetics and orthotics:
(1) telephone responses to
questions;
(7) orientation and training regarding proper
use of the item;
(8) preparation
and maintenance of necessary records required under
7
AAC 105.230 and 7 AAC120.210.
(k) The department may enter into a contract
under AS 36.30, a grant, or other arrangement permitted by law with a
prosthetics and orthotics provider enrolled under this section, authorizing
that provider to provide prosthetics or orthotics.
(l) A prosthetics and orthotics provider
enrolled under this section may not make unsolicited contact with a recipient
of medical assistance under 7 AAC 100 for the purpose of marketing the
provider's products or services.
(m) A prosthetics and orthotics provider
enrolled under this section may request payment for the reasonable costs of
follow-up fittings and adjustments on a per 15-minute basis unless these
services were included in and previously reimbursed under a bundled
rate.
Authority:AS
47.05.010
AS 47.07.030
AS
47.07.040
