Current through November 28, 2024
(a) Payment by the department to a provider
enrolled under
7
AAC 105.210 as a durable medical equipment provider
will be made in accordance with this section.
(b) A provider enrolled under
7
AAC 105.210 as a durable medical equipment provider
providing durable medical equipment, medical supplies, prefabricated
off-the-shelf orthotics, or related items and services under
7
AAC 120.200(a)(2) to eligible
recipients may submit, as follows, claims covered in the Healthcare
Common Procedure Coding System (HCPCS), adopted by reference in
7
AAC 160.900, for which a rate or rate methodology has
been established by CMS or the department or for covered codes with
rate-setting methodologies set out in (c) - (e) of this section:
(1) payment rates set by the department for
items and services provided by enrolled providers to recipients physically
located in this state will be based on 100 percent of the current quarter's
Medicare DMEPOS Fee Schedule established by CMS for these items and services in
this state;
(2) payment rates set
by the department for items and services provided to recipients when the
recipient is physically located outside of this state will be based on 100
percent of the current quarter's Medicare DMEPOS Fee Schedule established by
CMS for these items and services in the state where the item or service was
provided;
(3) payment rates set by
the department for items and services not established on the current quarter's
Medicare DMEPOS Fee Schedule will be based on the methodology set out in (c) -
(f) of this section.
(c)
Payment rates for durable medical equipment, medical supplies, prefabricated
off-the-shelf orthotics, or related items and services under
7
AAC 120.200(a)(2) for covered
non-miscellaneous codes that are from the Healthcare Common Procedure
Coding System (HCPCS), adopted by reference in
7
AAC 160.900, but for which CMS has not issued a rate
on the current quarter's Medicare DMEPOS Fee Schedule as described in (b) of
this section or for which the department has not established a rate and
published the rate on the Alaska Medicaid DMEPOS Fee Schedules, Tables
1-5 through 1-9, adopted by reference in
7
AAC 160.900, or Alaska Medicaid DMEPOS Interim
Fee Schedule, will be based on the submitted unaltered final \
purchase invoice price plus 35 percent, as follows, for claims submitted on or
after {effective date of regulations} and before the date the rate is
established, until a rate is set by CMS or the department:
(1) if the median unaltered final purchase
invoice price of the non-miscellaneous HCPCS item for the first 10 claims is
less than $5,000, the final rate will be set at
(A) the median submitted unaltered final
purchase invoice price of the first 10 claims plus 35 percent if the first 10
claims were paid to at least two different enrolled providers; or
(B) the median submitted unaltered final
purchase invoice price of the number of claims paid, plus 35 percent after 15
claims are paid but have not been paid to at least two different enrolled
providers;
(2) if the
median unaltered final purchase invoice price of the non-miscellaneous HCPCS
item for the first 10 claims is $5,000 or more, the final rate will be set at
(A) the median submitted unaltered final
purchase invoice price plus 30 percent if the first 10 claims were paid to at
least two different enrolled providers; or
(B) the median submitted unaltered final
purchase invoice price of the number of claims paid, plus 30 percent after 15
claims are paid but have not been paid to at least two different enrolled
providers;
(3) when
applicable, the rental rates for a covered item non-priced, non-miscellaneous
HCPCS code for which CMS or the department has not issued a permanent rate will
be 10 percent of the rate set out in (1) of this subsection;
(4) all claims paid under this subsection
must be submitted with an unaltered final purchase invoice, free of alteration
described in (o) of this section; claims submitted without an unaltered final
purchase invoice or with anything other than an unaltered final purchase
invoice will be denied.
(d) Payment rates for covered items submitted
using a miscellaneous HCPCS code as defined in
7
AAC 120.399 for which CMS or the department has not
issued a rate as described in (b) of this section will be paid, as follows, at
the unaltered final purchase invoice price plus 20 percent:
(1) the department will not set a generic
rate for the miscellaneous HCPCS code, but the department may set a rate based
on a national drug code product identifier or other product identifier and may
require the unique identifier to be submitted on claims to facilitate
payment;
(2) claims submitted for
miscellaneous HCPCS codes under this section for which a product-specific rate
has not been established and published on the Alaska Medicaid DMEPOS Fee
Schedules, Tables 1-5 through 1-9, adopted by reference in
7
AAC 160.900, or Alaska Medicaid DMEPOS Interim Fee
Schedule must be submitted with an unaltered final purchase invoice, free of
alteration described in (o) of this section; claims submitted without an
unaltered final purchase invoice or with anything other than an unaltered final
purchase invoice will be denied;
(3) when applicable, for a covered item
defined under a miscellaneous code for which CMS or the department has not
issued a price, the rental rate will be 10 percent of the purchase invoice
price plus 20 percent.
(e) Rates established by the department under
this section for a covered code for which CMS has not issued a rate may be
published on the department's Alaska Medicaid DMEPOS Interim Fee
Schedule.
(f) A provider
enrolled under
7
AAC 105.210 as a durable medical equipment provider
may submit claims for labor and repair parts for damaged durable medical
equipment, medical supplies, prefabricated off-the-shelf orthotics, and related
items and services under
7
AAC 120.200(a)(2) with the following
limitations:
(1) the department will not pay
more than the corresponding labor rate listed on the
Alaska Medicaid
DMEPOS Fee Schedule, Tables 1-5 through 1-9, adopted by reference in
7
AAC 160.900, for which CMS has issued a price for each
15 minutes of labor costs;
(2) the
billing for a repair part must reflect a charge that complies with the
applicable standards in
7
AAC 145.020 and this section;
(3) labor and repair parts for the item must
be documented and the documentation must be submitted with each claim;
documentation must include
(A) a statement
signed by the recipient or the recipient's authorized representative that
describes the cause for and nature of the repair;
(B) a description of the item being repaired
and its serial number, if available;
(C) the beginning and end dates of warranty
coverage, if available;
(D)
documentation for labor charges that includes the amount of time spent on the
repair, rounded up to the nearest quarter hour, and the hourly rate charged for
the repair; and
(E) an itemized
list of parts used in the repair and associated costs;
(4) a provider may not submit a claim for
labor and repair parts if the item is covered under a manufacturer's or
supplier's warranty, or if the labor or parts are necessary to repair an item
that needs repair because of a manufacturer's defect;
(5) a provider may not submit a claim for
labor and repair parts for a rented item; the provider shall ensure that a
rented item functions as intended after the provider repairs or replaces the
item.
(g) A provider
enrolled under
7
AAC 105.210 as a durable medical equipment provider
may submit claims for the following incontinence supplies up to the allowed
quantities listed on the Alaska Medicaid DMEPOS Fee Schedule, Tables 1-5
through 1-9, adopted by reference in
7
AAC 160.900, except that if a service authorization
has been approved to exceed the allowed quantities based on medical necessity,
payment will be determined on those supplies based on the Alaska Medicaid
DMEPOS Fee Schedule, Tables 1-5 through 1-9, adopted by reference in
7
AAC 160.900:
(6) disposable washcloths.
(h) For a rental period that is 30
days or more, the department will pay for rented durable medical equipment at
the lesser of a monthly rental rate of 10 percent of the allowed purchase rate
under this section or the billed rental charge, except
(1) codes that are from the Healthcare Common
Procedure Coding System (HCPCS), adopted by reference in
7
AAC 160.900, that are defined as rental codes or with
a specific rental rate listed on the Alaska Medicaid DMEPOS Fee Schedule,
Tables 1-5 through 1-9, adopted by reference in
7
AAC 160.900, may pay at the rental price listed on the
Alaska Medicaid DMEPOS Fee Schedule or Alaska Medicaid DMEPOS Interim Fee
Schedule:
(2) capped rental items
or services may be paid at the rental rate listed on the Alaska Medicaid DMEPOS
Fee Schedule, Tables 1-5 through 1-9, adopted by reference in
7
AAC 160.900, or on the Alaska Medicaid DMEPOS Interim
Fee Schedule up to the lesser of the purchase price of the item or 13 months'
worth of continuous rental.
(i) For a rental period that is less than 30
days, the department will pay for rented durable medical equipment, medical
supplies, prefabricated off-the-shelf orthotics, or related items and services
under 7 AAC
120.200(a)(2) at a monthly rental
rate of 150 percent of the monthly fee in (h) of this section, divided by the
number of days in the month, times the number of days in the rental period.
Payment may not exceed the monthly rate. Codes that are from the Healthcare
Common Procedure Coding System (HCPCS), adopted by reference in
7
AAC 160.900, that are defined as daily rental codes or
with a specific daily rate identified on the Alaska Medicaid DMEPOS Fee
Schedule, Tables 1-5 through 1-9, adopted by reference in
7
AAC 160.900, will pay at the lesser of the rental
price listed on the Alaska Medicaid DMEPOS Fee Schedule, the Alaska Medicaid
DMEPOS Interim Fee Schedule, or the billed rental rate.
(j) A provider enrolled under
7
AAC 105.210 as a durable medical equipment provider
may submit claims and payment may be authorized at a rate higher than the
state-based rate published on the Alaska Medicaid DMEPOS Fee Schedule, Tables
1-5 through 1-9, adopted by reference in
7
AAC 160.900, for a more costly, medically necessary
item of durable medical equipment, medical supply, prefabricated off-the-shelf
orthotic, or related item or service under
7
AAC 120.200(a)(2) if the recipient's
medical condition substantiates the need, and documentation is submitted with
the claim that demonstrates, as follows, that a less expensive product is not
available to meet the medical needs of the recipient:
(1) the provider may request a higher
reimbursement rate by submitting the alternate reimbursement rate request form,
available on the department website, with the claim and the required
documentation with the claim;
(2)
an approved request will be reimbursed at the actual acquisition cost, as
substantiated by a submitted final, unaltered invoice, free of alteration
described in (o) of this section, plus
(A) 35
percent for items with an actual acquisition cost below $5,000; or
(B) 30 percent for items with an actual
acquisition cost at or above $5,000;
(3) enteral nutrition products assigned a "B"
code under the Healthcare Common Procedure Coding System (HCPCS), adopted by
reference in
7
AAC 160.900, and incontinence supplies assigned a "T"
code are not eligible for reimbursement rates higher than those published on
the Alaska Medicaid DMEPOS Fee Schedule, Tables 1-5 through 1-9, or the Alaska
Medicaid DMEPOS Interim Fee Schedule.
(k) Subject to the applicable provisions of
7
AAC 120.200 -
7
AAC 120.399, a provider enrolled under
7
AAC 105.210 as a durable medical equipment provider
may request payment for the reasonable direct costs of delivery or shipping, as
follows:
(1) from the manufacturer to the
provider for customized or optimally configured durable medical equipment
repair and replacement parts that are specialized or unique to a recipient's
equipment or service and for which the final unaltered purchase invoice price
exceeds $250; the shipping method used must be the most cost-effective method
available; the unaltered final purchase invoice, free of alterations described
in (o) of this section, must include the purchase invoice for the replacement
items or repair and must include shipping costs; if the unaltered final
purchase invoice is free of alterations described in (o) of this section but
contains one or more items in addition to the repair or replacement part, the
department will pay for the shipping cost attributed to the repair or
replacement part, as calculated by dividing the shipping cost on the unaltered
final purchase invoice by the number of items purchased and multiplying by the
number of repair or replacement parts specific to the recipient's need;
expedited, next day, rush, or delivery charges resulting from the use of a
shipping method other than the most cost-effective method available will not be
covered;
(2) from the dispensing
provider to the recipient when 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 enrolled under
7
AAC 105.210 in the municipality where the recipient
resides;
(C) the submitted claim
and supporting documents include the
(ii) address to
where the item was delivered;
(iii)
itemized list of the products included in the shipment or delivery, to include
each product name, each product identifier, the quantity, and the serial
number, when applicable;
(iv)
shipment and delivery date;
(v)
recipient's signature with the date of receipt; and
(vi) total shipping and delivery charges
minus all discounts, substantiated by a paid shipping invoice reflecting the
actual payment;
(3) from the recipient to the dispensing
provider for the repair of recipient-owned equipment when 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 enrolled under this section in the municipality
where the recipient resides;
(C)
the submitted claim and supporting documents include the (i) address to where
the item was delivered; (ii) itemized list of the products included in the
shipment or delivery, to include each product name, each product identifier,
the quantity, and the serial number, when applicable; (iii) shipment and
delivery date; (iv) recipient's signature with the date of receipt; and (v)
total shipping and delivery charges minus all discounts, substantiated by a
paid shipping invoice reflecting the actual payment; (4) shipping costs that
qualify for coverage under this section due to the recipient traveling within
or outside of this state; those costs are eligible for coverage only if the
recipient is traveling for medical, educational, or vocational reasons;
documentation from the prescribing physician supporting the recipient's reason
for travel and including the estimated duration of travel must be submitted
with the claim; shipping costs related to recreational travel are not covered.
(l) Used or
refurbished durable medical equipment, medical supplies, prefabricated
off-the-shelf orthotics, or related items and services under
7
AAC 120.200(a)(2) will be reimbursed
at not more than 75 percent of the allowed rate for the specific item as
described in (b) - (e) of this section.
(m) Enteral nutrition products assigned a "B"
code under the Healthcare Common Procedure Coding System (HCPCS), adopted by
reference in
7
AAC 160.900, and incontinence supplies assigned a "T"
code must be billed with the respective specific manufacturer product code
dispensed and the correct corresponding HCPCS code and modifier as set out on
the Alaska Medicaid DMEPOS Fee Schedule, Tables 1-5 through 1-9, adopted by
reference in
7
AAC 160.900, to be eligible for payment. Enteral
product and incontinence supply reimbursement will be consistent with this
section and are not eligible for higher allowable adjustment
requests.
(n) Providers may use the
department's price research form to request formal research of a state-based
specific price established by the department that has not been established by
CMS using the Alaska Medicaid DMEPOS Price Research Form.
(o) An unaltered final purchase invoice is
considered altered if
(1) information on the
original invoice is removed, erased, redacted, omitted, or otherwise modified
so that the copy submitted to the department is anything other than an exact
copy of the original invoice received by the enrolled provider from the
provider's supplier; legible markings made by an enrolled provider on the
original invoice as part of the enrolled provider's normal business practices
will not result in the department viewing an invoice as altered if the markings
(A) do not remove, erase, redact, omit, or
otherwise modify the invoice in a way that results in any of the information on
the original invoice becoming illegible; and
(B) appear on both the original invoice and
the copy submitted to the department; or
(2) the invoice shows a price other than the
final price paid by the enrolled provider.
(p) The Alaska Medicaid DMEPOS Fee Schedule,
Tables 1-5 through 1-9, adopted by reference in
7
AAC 160.900, will be available quarterly in accordance
with published CMS Medicare DMEPOS fee schedules.
(q) In this section,
(1) "out-of-state" means that the provider is
physically located in a state other than this state;
(2) "in-state" means that the provider is
physically located in this state.
Quarterly current and historical Centers for Medicare and
Medicaid Services (CMS) Medicare DMEPOS Fee Schedules are available on the CMS
website at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Scheduled.html.
The department's Alaska Medicaid DMEPOS Interim Fee
Schedule and Alaska Medicaid DMEPOS Price Research Form, referenced in 7 AAC
145.420. 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.coni/Droviders/FeeSchedule.aspandwww.medicaidalaska.coni/Droviders/forms.html.
Authority:AS
47.05.010
AS 47.07.030
AS
47.07.040
