Alaska Administrative Code
Title 7 - Health and Social Services
Part 8 - Medicaid Coverage and Payment
Chapter 140 - Medicaid Coverage; Facility and Facility-Based Services
Article 4 - Hospital Services
7 AAC 140.315 - Noncovered hospital services
Universal Citation: 7 AK Admin Code 140.315
Current through November 28, 2024
(a) Except as otherwise provided in 7 AAC 105 - 7 AAC 160, the department will not pay for services
(1) identified as noncovered services
in 7 AAC 105.110; or
(2) for which a revenue code is not listed as
described in
7
AAC 140.310(a).
(b) Except as otherwise provided in 7 AAC 105 - 7 AAC 160, the department will not pay a hospital for the following services and procedures:
(1) a service that is not
within the scope of the facility's licensure, certification, or
accreditation;
(2) the following
services, unless the department gives prior authorization specifically for the
service:
(A) the dispensing of
antabuse;
(B) methadone treatment,
including the dispensing of methadone;
(C) alcohol or drug detoxification or
rehabilitation;
(3)
tobacco cessation therapy and services; however, the department will pay for
tobacco cessation products;
(4)
leaves of absence, including charges for holding a recipient's room or bed,
except as described under
7
AAC 140.585 when a recipient is in a hospital's
long-term care facility;
(5)
services and procedures that do not require hospital care, including
(A) outpatient special residence charges,
rest cures, daily respite care under
7
AAC 130.280, adult day services, or day care for
children;
(B) room and board for
individuals other than the patient, unless the department gives prior
authorization specifically for the service;
(C) admission solely for the purpose of
medical and dental services, surgical procedures, or diagnostic testing that
can be performed on an outpatient basis or in an ambulatory surgical center;
however, the department will give prior authorization specifically for a
service, procedure, or test if the recipient's
(i) current medical condition or physical or
mental disabilities are sufficiently severe that performing that service,
procedure, or test on an outpatient basis or in an ambulatory surgical center
would seriously endanger the recipient's health; or
(ii) recent medical history indicates that
performing that service, procedure, or test on an outpatient basis or in an
ambulatory surgical center would seriously endanger the recipient's
health;
(D) recipients
who do not require or who no longer require acute inpatient care; however, the
department will make a payment to the hospital for accommodation when no
long-term care bed is available, if the department has approved the level of
care appropriate for the recipient in situations involving a swing bed or
administrative-wait bed;
(E)
custodial care related to court commitments; patients confined to a hospital
under a court commitment for any reason will be covered for payment only to the
extent medical necessity exists for inpatient hospital care;
(F) recipients remaining beyond the length of
stay authorized under
7
AAC 140.320;
(G) recipients pending discharge when
hospital care is no longer required;
(H) days of care due to failure to promptly
request or perform necessary diagnostic studies, medical-surgical procedures,
or consultations;
(I) disability
examinations, except that the department will pay for outpatient tests ordered
by a physician as part of
(i) an initial
disability examination in accordance with
7
AAC 40.180; or
(ii) a review of a disability determination
in accordance with
7
AAC 40.190;
(J) evaluative or periodic checkups,
examinations, or immunizations that are connected with the participation in,
enrollment in, attendance at, or accomplishment of a program or activity
unrelated to the recipient's physical or mental health or rehabilitation,
except mammograms;
(6)
organ transplants and related services, and dental implants, except that the
department will make payment for organ transplants and requisite related
medical care for
(A) kidney and corneal
transplants; prior authorization is not required;
(B) skin and bone transplants for which the
department has given prior authorization;
(C) bone marrow transplants for which the
department has given prior authorization;
(D) liver transplants for which the
department has given prior authorization, for persons with biliary atresia or
other forms of end-stage liver disease; and
(E) heart, lung, and heart-lung transplants
for which the department has given prior authorization;
(7) weekend stays if admission was made on
Friday or Saturday for surgery scheduled on Monday, except for an emergency or
situation where the physical or mental condition of the patient necessitates
extensive preoperative preparation or therapy;
(8) professional fees in addition to those
typically charged within specific cost centers, including osteopathic services,
and except registered nurse anesthetist services;
(9) separately identifiable preventive care
services, clinic services, medical social services, and trauma team response
activation charges;
(10) nursing
services and incremental nursing charges assessed in addition to accommodation
charges, including private-duty nursing charges;
(11) take-home drugs, oxygen, and supplies
not otherwise classified;
(12) home
infusion therapy;
(13)
miscellaneous home dialysis charges;
(14) educational services and
supplies;
(15) cardiac
rehabilitation that exceeds the guidelines in the Medicare National
Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10
(Cardiac Rehabilitation Programs), adopted by reference in
7
AAC 160.900;
(16) recreational therapy and medical
rehabilitation day programs;
(17)
charges for services or items normally considered part of routine services and
optional or special services not directly related to medical care, including
(A) private accommodation charges, unless
medically necessary;
(B) deluxe
accommodation charges;
(C) patient
convenience items; and
(D) routine
service charges for accommodations that cannot be included in more specific
revenue codes;
(18)
personal services not normally associated with hospital care, including
long-distance telephone calls, television rental, guest meals, and personal
items.
(c) The department will not pay for a service or inpatient stay for which prior authorization is denied, or is required but not obtained, including nonemergency out-of-state services for which prior authorization is not obtained under 7 AAC 105.130.
(d) Repealed 3/19/2014.
(e) Except as provided in (f) of this section, the department will not pay a hospital for the following provider-preventable conditions:
(1) services
and procedures related to a health care-acquired condition as defined in
42 C.F.R.
447.26(b), adopted by
reference in
7
AAC 160.900;
(2) a wrong surgical or other invasive
procedure performed on a patient;
(3) a surgical or other invasive procedure
performed on the wrong body part;
(4) a surgical or other invasive procedure
performed on the wrong patient.
(f) A reduction in payment resulting from a provider-preventable condition identified in (e) of this section will be abrogated in accordance with 42 C.F.R. 447.26(c)(2) or limited in accordance with 42 C.F.R. 447.26(c)(3). The provisions of 42 C.F.R. 447.26(c) are adopted by reference in 7 AAC 160.900.
(g) In this section, "cost center" has the meaning given in 7 AAC 150.990.
Authority:AS 47.05.010
AS 47.07.030
AS 47.07.040
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