Alaska Administrative Code

(a) If the department has reason to believe that an individual has committed an intentional program violation or program abuse, the department will conduct a full investigation in accordance with 42 C.F.R. 455.15. If, after a full investigation, the department determines that an …

The United States Department of Health and Human Services federal poverty guidelines for this state, established in 72 Fed. Reg. 3147 - 3148, revised as of January 24, 2007, and as amended from time to time, are adopted by reference. Notes 7 AAC 100.980 Eff. 7/20/2007, Register 1…

In this chapter, unless the context requires otherwise, (1) "AB" means aid to the blind under former 42 U.S.C. 1201 (Title X of the Social Security Act); (2) "adoption" means the establishment of a parent-child relationship between a child and an adult who is not the child's birt…

The department will pay for a service only if that service (1) is identified as a covered service in accordance with AS 47.07 and 7 AAC 105 - 7 AAC 160; (2) is provided to an individual who is eligible for Medicaid under 7 AAC 100 on the date of service; (3) is ordered or prescri…

Unless otherwise provided in 7 AAC 105 - 7 AAC 160, the department will not pay for a service that is (1) not reasonably necessary for the diagnosis and treatment of an illness or injury, or for the correction of an organic system, as determined upon review by the department or t…

(a) Unless otherwise provided in 7 AAC 105 - 7 AAC 160, the department will cover a service provided out of state to the same extent it would cover the service provided in this state if (1) the service is provided to a recipient who is a resident of this state; and (2) the depart…

(a) Except as otherwise provided in 7 AAC 105 - 7 AAC 160, the department will not pay for the following services unless the department has given prior authorization for the service: (1) nonemergency, medically necessary transportation and accommodation services; (2) a specific h…

(a) Notwithstanding the provisions of 7 AAC 105.610, 7 AAC 110.750, 7 AAC 120.112, 7 AAC 145.400, and 7 AAC 145.410, the department may make adjustments to covered services listed under (b) of this section for the length of a declared disaster emergency if(1) the governor issues …

(a) Subject to all other requirements of 7 AAC 105 - 7 AAC 160, the following types of providers are eligible to enroll with the department and bill directly for services rendered: (1) a person with an active license under AS 08, or under the laws of the jurisdiction in which the…

(a) An eligible provider shall enroll with the department before billing the department for payment of services covered under 7 AAC 105 - 7 AAC 160 that are provided to recipients. (b) To be enrolled in this state, a provider (1) must submit a completed provider enrollment form a…

(a) Providing medical or medically related services to recipients or billing the department for those services constitutes agreement by the provider to (1) comply with all applicable federal and state laws related to providing medical or medically related services to Medicaid rec…

(a) A provider (1) shall maintain accurate financial, clinical, and other records necessary to support the services for which the provider requests payment; (2) shall ensure that the provider's staff, billing agent, or other entity responsible for the maintenance of the provider'…

(a) At the request of the department, the department's fiscal agent, the Department of Law, or a representative of the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), a provider shall provide the records described in 7 AAC …

When payment is received by a provider from a recipient, relative, recipient's estate, health insurance, or other source, for a covered service that has been or will be paid for by the department, the provider must refund or credit to the department an equivalent amount, up to th…

(a) An overpayment occurs when the department pays a provider (1) for a service without prior authorization when prior authorization is required under 7 AAC 105 - 7 AAC 160; (2) an amount that exceeds the maximum dollars or units allowed under 7 AAC 105 - 7 AAC 160; (3) for a ser…

(a) A provider may request a first-level appeal of a denied or reduced claim or service under this section if no later than 180 days after the date on the remittance advice for the claim, a provider submits to the department's designee (1) a written request for a first-level appe…

(a) A provider may appeal a first-level appeal decision under 7 AAC 105.270(a) - (f) if the provider submits a written request to the department no later than 60 days after the date of the first-level appeal decision. (b) A provider that appeals a first-level appeal decision unde…

Upon request by the department, a hospital or physician shall provide a full operative report, interpretation of any film, or a pathologist's report on tissue removed. The department will not pay a hospital or physician provider for a procedure that requires an operative report o…

The department may impose sanctions for one or more of the following reasons: (1) presenting or causing to be presented for payment any false or fraudulent claim for services or supplies; (2) submitting or causing to be submitted false information for the purpose of obtaining gre…

(a) The department may impose the following sanctions against a provider based on the grounds specified in 7 AAC 105.400: (1) termination from participation in the Medicaid program; (2) suspension of participation in the Medicaid program; (3) restriction or withholding of payment…

(a) Except as provided under (c) of this section, if one or more grounds for sanction exist under 7 AAC 105.400, the department will determine which sanction to impose under 7 AAC 105.410. (b) The department will consider the following factors in determining the sanction to be im…

(a) If the department has suspended or terminated a provider from participation in the Medicaid program under 7 AAC 105.420(c), that provider may not submit a claim, either directly or through another entity, for payment for any service provided to a recipient (1) on or after the…

(a) When the department determines that a sanction against a provider is warranted under 7 AAC 105.400 - 7 AAC 105.420, the department will send written notice of the determination to the provider by certified mail. In the notice, the department will include(1) the grounds for sa…

(a) Unless the department has terminated a provider's participation in the Medicaid program under 7 AAC 105.420, a provider who has received a sanction must participate in a provider education program as a condition of continued participation in the Medicaid program. (b) For each…

(a) No more than 30 days after the date on the notice of sanction, the provider receiving the notice may request an appeal and a formal hearing. The request for appeal must be in writing and contain a statement and supporting documents that describe the alleged grounds for sancti…

(a) The department may place restrictions on the payment of claims submitted by the provider, including the necessity of the provider to obtain prior authorization of services or to submit to prepayment review of claims, if (1) the department has reason to believe, based on relia…

(a) The department may temporarily withhold medical assistance payments to a provider under 7 AAC 105.410, in whole or in part, upon receipt of reliable information that the circumstances giving rise to the need for the withholding involve medical assistance fraud as defined in A…

In 7 AAC 105.400 - 7 AAC 105.490, (1) "closed-end provider agreement" means an agreement that is for a specific period of time not to exceed 12 months and that must be renewed in order for the provider to continue to participate in the Medicaid program; (2) "termination from part…

(a) The department may restrict a recipient's choice of medical providers if the department finds that a recipient has used Medicaid services at a frequency or amount that is not appropriate as provided in (b) of this section. (b) A recipient's use of Medicaid services is not app…

(a) Except as provided in (b) of this section, a person eligible for Medicaid under 7 AAC 100 shall pay the following cost-sharing amounts: (1) $50 per day up to a maximum of $200 per discharge for inpatient hospital services; (2) five percent of allowable charges for outpatient …

(a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing advanced practice registered nurse services, including nurse midwife services, a provider must be an independent practicing advanced practice registered nurse who (1) is enrolled in as an advanced practice r…

(a) The department will pay an advanced practice registered nurse who meets the requirements of 7 AAC 110.100 for services provided that are within the scope of the advanced practice registered nurse license to practice, including (1) primary care, including (A) diagnosis and tre…

(a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing chiropractic services, a chiropractor must (1) be enrolled as a chiropractor in accordance with 7 AAC 105.210; (2) have an active license to practice chiropractic issued by the jurisdiction in which the chir…

(a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing dental services, a dentist must(1) be enrolled as a dentist in accordance with 7 AAC 105.210; (2) have an active license to practice dentistry issued by the jurisdiction in which the dentist provides service…

(a) Payment for emergent dental services covered under this subsection does not reduce a recipient's annual limit under (b) and (c) of this section. Except as specifically excluded under (g) of this section, the department will pay for the following emergent dental services ident…

(a) Except as provided in 7 AAC 110.200(3), the department will pay for the services identified in the Fee Schedule: Dental Services for Children, adopted by reference in 7 AAC 160.900, as follows, provided to a recipient under 21 years of age: (1) periodic oral evaluation not mo…

(a) The department will pay a provider for only those orthodontic dental services identified in the Fee Schedule: Dental Services for Children, adopted by reference in 7 AAC 160.900, and that have prior authorization form the department. The department will pay for orthodontic se…

(a) The department will pay for nitrous oxide sedation, intramuscular sedation, or nonintravenous conscious sedation required for dental services covered under 7 AAC 110.145 - 7 AAC 110.155 if the dental services provider justifies, in writing, that local anesthesia is inadequate…

Notes 7 AAC 110.160 Eff. 2/1/2010, Register 193; repealed 12/1/2022, Register 244, January 2023 State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More compariso…

(a) Payment for dental hygiene services provided under this section to recipients 21 years of age and older reduces the recipient's annual dental limit under 7 AAC 110.145(b) and the associated unused services provisions of 7 AAC 110.145(e). (b) Prior authorization requirements u…

(a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing direct-entry midwife services, a direct-entry midwife must (1) be enrolled as a direct-entry midwife in accordance with 7 AAC 105.210; and (2) have an active license or certification to practice as a direct-…

The department will pay for early and periodic screening, diagnosis, and treatment (EPSDT) services provided to a recipient under 21 years of age. EPSDT services include (1) screening for physical, behavioral, vision, dental, and hearing needs that meet the requirements of 7 AAC …

(a) To be covered under 7 AAC 105 - 7 AAC 160, an EPSDT screening must be performed by one or more of the following providers enrolled under 7 AAC 105 - 7 AAC 160: (1) a physician; (2) a licensed or certified health care practitioner who performs a screening under the supervision…

(a) The department will pay for a service recommended as a result of the EPSDT screening, if that service is an authorized service under 42 U.S.C. 1396- 1396w-1. (b) The department will pay for the following additional services for children under 21 years of age if the screening …

(a) The department will pay for family planning services authorized under this section if those services are provided by one of the following enrolled providers: (1) a family planning clinic of the department; (2) a family planning clinic of a local governmental health department…

To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing in-state freestanding or portable x-ray services the provider must be enrolled as a provider of those services in accordance with 7 AAC 105.210, and must (1) be certified by the department under 42 C.F.R. 488.11…

(a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing registered nurse anesthetist services directly to a recipient, a provider must (1) be enrolled as a registered nurse anesthetist under 7 AAC 105.210; and (2) except as provided in (b) of this section, hold a…