Current through November 28, 2024
(a) Payment by the
department to a provider that is enrolled under
7
AAC 120.300 as a prosthetics and orthotics provider
will be made in accordance with
7
AAC 145.020.
(b) A provider enrolled under
7
AAC 120.300 as a prosthetics and orthotics provider
providing prosthetics, orthotics, related medical equipment, items, and
supplies to eligible recipients may submit claims covered by the
Healthcare Common Procedure Coding System (HCPCS), adopted by
reference in
7
AAC 160.900, for which a rate has been established by
CMS or the department or for covered codes with rate-setting methodologies set
out in (c) - (e) of this section, as follows:
(1) payment rates set by the department for
items and services provided by providers enrolled under
7
AAC 120.300 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, except
items and services billable only by providers enrolled under
7
AAC 120.300 will be based on 120 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 by providers enrolled under
7
AAC 120.300 who provide services to recipients when
the recipients are 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; the department will base location on the provider's Medicare
accreditation location address;
(3)
payment rates set by the department for items and services not established on
the current quarter's Medicare DMEPOS Fee Schedule established by CMS will be
based on the rate-setting methodology set out in (c) - (f) of this
section.
(c) Payment
rates for prosthetics, orthotics, or related items and services under
7
AAC 120.300(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 (k) 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, except when the
covered item is a customized prosthetic or orthotic item manufactured under the
oversight of and signed off by a certified professional described in
7
AAC 120.300(a)(2)(C):
(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 product code 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 (k) of this section; claims submitted
without an unaltered final purchase invoice or with anything other than an
unaltered final purchase invoice will be denied.
(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 120.300 as a prosthetics and orthotics provider
may submit claims for labor and repair parts for damaged prosthetics,
orthotics, and related items and services 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) Payment using
a miscellaneous HCPCS code as defined in
7
AAC 120.399 for custom-fabricated prosthetics,
orthotics, and related items and services manufactured under the oversight of
and signed off by a certified professional described in
7
AAC 120.300(a)(2)(C) will be based on
the most applicable HCPCS code at the lesser of
(2) a price ceiling based on the following
calculation:;
(A) for items with more than 10
parts, an itemized list of the cost, with no provider mark-up, of up to 10
parts, with the total cost multiplied by 180 percent; or
(B) an itemized list of the cost, with no
provider mark-up, of all parts used to manufacture the custom prosthetic or
orthotic, with the total cost multiplied by 160 percent; additionally, charges
and costs under this subparagraph include the following:
(i) a labor charge priced at the L7520
payment rate of the
HCPCS per 15 minutes; and
(ii) additional bundled costs paid up to
$1,064.10; the bundled cost items include the initial evaluation, diagnostic
checks, and follow-up.
(h) A provider enrolled under
7
AAC 120.300 as a prosthetics and orthotics provider
may request reimbursement for labor and parts costs associated with adjustments
to a prosthetic medically necessary to prevent injury to the residual limb due
to residual limb measurement changes that do not require a full new customized
prosthetic.
(i) Subject to the
applicable provisions of
7
AAC 120.300 -
7
AAC 120.399, a provider enrolled under
7
AAC 120.300 as a prosthetics and orthotics 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 and for which the final unahered purchase invoice price exceeds $250;
the shipping method used must be the most cost-effective method available; the
unahered final purchase invoice, free of alterations described in (k) 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 (k) of this section but contains one or more
item 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 120.300 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.
(j) 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.
(k) 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.
(l) 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.
(m) 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-Schedule.html.
The department's Alaska Medicaid DMEPOS Interim
Fee Schedule and Alaska Medicaid DMEPOS Price Research Form,
referenced in 7 AAC 145.421, 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
and www.medicaidalaska.com/providers/forms.html.
Authority:AS
47.05.010
AS 47.07.030
AS
47.07.040
