reglab/statecodes huggingface dataset:
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 3 - Provider Sanctions and Remedies › 7 AAC 105.410 - Sanctions

Current through May 31, 2024
(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 payments to a provider;
(4) referral to a utilization and quality
				  control peer-review organization;
(5) transfer to a closed-end provider
				  agreement not to exceed 12 months or the shortening of an already-existing,
				  closed-end provider agreement;
(6)
				  mandatory attendance at provider education sessions, including one-on-one
				  sessions;
(7) requirement of prior
				  authorization of services;
(8)
				  department review of all claims submitted by a provider before payment to the
				  provider;
(9) referral to the
				  applicable jurisdiction licensing board for investigation;
(10) referral for fiscal audit under
				  7 AAC 160.110;
(11) public notice of suspension or
				  termination of a provider;
(12)
				  reporting the provider to the Healthcare Integrity and Protection Data Bank
				  authorized under  45 C.F.R. Part 61 ;
(13) restrictions on payment under
				  7 AAC 105.470.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 3 - Provider Sanctions and Remedies › 7 AAC 105.420 - Imposition of sanction

Current through May 31, 2024
(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 imposed:
(1) seriousness of the offense;
(2) extent of violations;
(3) history of prior violations;
(4) prior imposition of sanctions;
(5) prior provision of provider
				  education;
(6) provider willingness
				  to obey program rules;
(7) whether
				  a lesser sanction will be sufficient to remedy the problem; and
(8) actions taken or recommended by
				  peer-review groups or licensing boards.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 3 - Provider Sanctions and Remedies › 7 AAC 105.430 - Scope of sanction

Current through May 31, 2024
(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 date the provider was suspended or terminated; or
(2) before the date the provider was
				  suspended or terminated for which the provider had not yet submitted a claim to
				  the department for payment.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 3 - Provider Sanctions and Remedies › 7 AAC 105.440 - Notice of sanction

Current through May 31, 2024
(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
				  sanction under
				  7 AAC 105.400, including all relevant facts;
(2) the proposed sanction to be imposed by
				  the department under
				  7 AAC 105.410 -
				  7 AAC 105.420;
(3) whether the matter has been referred for
				  fiscal audit under
				  7 AAC 160.110;
(4) any action required of the provider;
				  and
(5) the provider's right to an
				  appeal under
				  7 AAC 105.460.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 3 - Provider Sanctions and Remedies › 7 AAC 105.450 - Provider education

Current through May 31, 2024
(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 provider who has received a
				  sanction, the department will determine the topics of the provider education
				  program, including
(1) claims form
				  completion;
(2) the use and format
				  of provider manuals;
(3) the use of
				  procedure codes;
(4) key provisions
				  of the Medicaid program;
(5)
				  payment rates; and
(6) how to
				  inquire about coding or billing problems.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 3 - Provider Sanctions and Remedies › 7 AAC 105.460 - Appeal of sanction

Current through May 31, 2024
(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
				  sanction, specify the basis upon which the sanction is challenged, and explain
				  the reasons that the provider is in compliance with 7 AAC 105 - 7 AAC 160. A
				  provider may request an expedited appeal of a notice of immediate suspension
				  issued under
				  7 AAC 160.140. A provider requesting an appeal or
				  expedited appeal under this section must submit the request to the
				  Commissioner's Office, Department of Health and Social Services, P.O. Box
				  110601, Juneau, Alaska, 99811-0601.
(b) Upon receipt of the request for appeal,
				  if the department is withholding or restricting payment, the department may
				  continue the withholding or restriction of payment until a final determination
				  is made regarding the appropriateness of the sanction.
(c) Upon receipt of a request for appeal, the
				  department will schedule a hearing to be held no more than 30 days after
				  receipt of the request. Notice of the date, time, and place of the hearing will
				  be sent to the provider and the provider's attorney or designated
				  representative.
(d) If the sanction
				  proposed by the department is termination of the provider's participation in
				  the Medicaid program based on a failure to meet a standard, including licensure
				  or registration, required by federal or state law for participation in the
				  Medicaid program, a formal hearing is not available.
(e) A party may appear and be heard at an
				  appeal proceeding under this section through an attorney or through a
				  designated representative.
(f) If a
				  provider does not submit a request for appeal or provide the information
				  required under (a) of this section 30 days or less after the date on the notice
				  of sanction under
				  7 AAC 105.440, the notice of sanction is the
				  department's final administrative action.
Authority:
AS
						47.05.010
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 3 - Provider Sanctions and Remedies › 7 AAC 105.470 - Restrictions on payments

Current through May 31, 2024
(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 reliable information, that the provider has violated its provider
				  agreement or an applicable statute or regulation, and the department is
				  reviewing, auditing, or investigating the provider's compliance with the
				  requirements of 7 AAC 105 - 7 AAC 160; or
(2) a state professional licensing or
				  certifying agency is investigating the provider for having committed fraud,
				  abuse, professional misconduct, unprofessional conduct, or a violation of a
				  statute or regulation.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 3 - Provider Sanctions and Remedies › 7 AAC 105.480 - Withholding of payments

Current through May 31, 2024
(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
				  AS
				  47.05.210. Regardless of whether it elects to
				  withhold payments under this section, the department will refer the information
				  described in this subsection to the Department of Law.
(b) Separate from any notice the department
				  issues under
				  7 AAC 105.440, the department will send written notice
				  to a provider before it withholds payment under this section. In the notice,
				  the department will
(1) state that payments
				  are being withheld in accordance with
				  42 C.F.R.
				  455.23 or an applicable provision of state
				  law;
(2) state that the withholding
				  is for a temporary period;
(3)
				  specify, when appropriate, each type of medical assistance claim to which the
				  withholding applies;
(4) specify,
				  when appropriate, general allegations that justify the withholding
				  action;
(5) cite the circumstances
				  under which the withholding will be terminated; and
(6) inform the provider of the right to
				  submit written evidence for consideration by the department.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 3 - Provider Sanctions and Remedies › 7 AAC 105.490 - Definitions

Current through May 31, 2024
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 participation" means a permanent exclusion from participation
				  in the Medicaid program;
(3)
				  "withholding of payments" means a reduction or adjustment of the amounts paid
				  to a provider on pending and subsequently submitted bills for purposes of
				  offsetting overpayments previously made to the provider.
Authority:
AS
						47.05.010
AS 47.05.200
AS 47.05.210
AS 47.05.220
AS 47.07.040
AS
						47.07.074
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 4 - Restriction of Recipient's Choice of Providers; Cost-Sharing › 7 AAC 105.600 - Restriction of recipient's choice of providers

Current through May 31, 2024
(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 appropriate if one or more of the following occur:
(1) the department identifies that the
				  recipient
(A) received prescriptions from one
				  or more providers for medications in total average daily doses that exceed
				  those recommended in
Drug Facts and Comparisons,
adopted by
				  reference in
				  7 AAC 160.900;
(B) during a period of three consecutive
				  months, received prescription drugs from three or more pharmacy
				  locations;
(C) during a period of
				  three consecutive months, received an opioid prescription from two or more
				  prescribers;
(D) during a period of
				  three consecutive months, paid cash two or more times for a United States Drug
				  Enforcement Administration-designated Schedule II - V drug;
(E) during a 30-day period, received
				  concurrent prescriptions for an opioid and benzodiazepine from more than one
				  prescriber;
(F) over a period of
				  nine consecutive months or longer, was dispensed medication containing
				  buprenorphine with an average daily dose of greater than 16 milligrams;
(G) during a period of not less
				  than three consecutive months, used a medical item or service with a frequency
				  that exceeds two standard deviations from the arithmetic mean of the frequency
				  of use of the medical item or service by recipients of medical assistance
				  programs administered by the department who have used the medical item or
				  service as shown in the department's most recent statistical analysis of usage
				  of that medical item or service;
(H) during a period of 12 consecutive months,
				  received treatment through an emergency department three or more times for a
				  non-emergent condition;
(I) for a
				  reason that was within the control of the recipient, traveled using
				  department-authorized transportation and failed to receive services for which
				  the travel was authorized; or
(J)
				  during a period of six consecutive months, failed to keep three or more
				  appointments for services covered under 7 AAC 105-7 AAC 160;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 105 - Medicaid Provider and Recipient Participation › Article 4 - Restriction of Recipient's Choice of Providers; Cost-Sharing › 7 AAC 105.610 - Recipient cost-sharing

Current through May 31, 2024
(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 hospital services;
(3)
				  $3 per day for physician services;
(4) for a covered outpatient drug described
				  in 7 AAC 120.110(b),
				  $0.50 for each prescription that is filled or refilled with a payment for
				  service of $50 or less, or $3.50 for each prescription that is filled or
				  refilled with a payment for service of greater than $50; however, a
				  cost-sharing amount is not required for
(A) a
				  prescription for a covered outpatient drug for a recipient eligible under
				  7 AAC 48.560 (chronic and acute medical assistance;
				  limited reimbursement for prescribed drugs and medical supplies); or
(B) a vaccine administered by a pharmacist
				  under 7 AAC 120.110(d).
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 1 - Advanced Nurse Practitioner Services › 7 AAC 110.100 - Advanced practice registered nurse enrollment requirements

Current through May 31, 2024
(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
				  registered nurse in accordance with
				  7 AAC 105.210;
(2) has an active license to practice as an
				  advanced nurse practice registered issued by the jurisdiction in which the
				  individual provides services; if services are provided in this state, the
				  individual must hold an active license under AS 08.68;
(3) has a current advanced practice
				  registered nurse certification in a specialty area of nursing granted by a
				  national certification body recognized by the licensing authority for advanced
				  practice registered nurse in the jurisdiction in which the advanced practice
				  registered nurse provides services; and
(4) if the advanced practice registered nurse
				  prescribes legend drugs, has a valid license endorsement issued by the
				  jurisdiction in which the individual provides services authorizing the advanced
				  practice registered nurse to prescribe legend drugs; if legend drugs are
				  prescribed in this state, the advanced practice registered nurse must be
				  authorized to prescribe drugs by the Board of Nursing under
				  12 AAC 44.440.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 1 - Advanced Nurse Practitioner Services › 7 AAC 110.105 - Advanced practice registered nurse services

Current through May 31, 2024
(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 treatment of an illness or
				  injury for children or adults; and
(B) vaccine products and administration, in
				  accordance with 7 AAC 110.750
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 2 - Chiropractic Services › 7 AAC 110.120 - Chiropractic coverage and limitations

Current through May 31, 2024
(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 chiropractor provides
				  services; if services are provided in this state, the individual must hold an
				  active license under AS 08.20.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 3 - Dental Services › 7 AAC 110.140 - Dental provider enrollment requirements

Current through May 31, 2024
(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 services; if
				  services are provided in this state, the individual must hold an active license
				  under AS 08.36; and
(3) if
				  practicing orthodontics or other dental specialty, have an active certification
				  or license under
				  AS
				  08.36.242 and 08.36.243.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 3 - Dental Services › 7 AAC 110.145 - Dental services for adults

Current through May 31, 2024
(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 identified in the
Fee Schedule:
				  Emergent Adult Dental Services
, adopted by reference in
				  7 AAC 160.900, for recipients 21 years of age or older, as
				  follows:
(1) the following dental services
				  for the immediate relief of pain or acute infection:
(A) limited oral evaluation not more than two times per fiscal
				  year;
(B) extractions; under this
				  subparagraph,
(i) a claim submitted for up
				  to two extractions in a single day must be accompanied by medical
				  justification; and
(ii) a provider
				  must obtain prior authorization from the department for three or more
				  extractions in a single day or four or more extractions in a 12-month
				  period;
(C) one
				  intraoral periapical radiograph to determine if an extraction is
				  necessary;
(D) anesthesia or
				  sedation in accordance with
				  7 AAC 110.155 and necessary for dental services covered
				  under this section; a claim submitted to the department for payment of costs
				  for general anesthesia must be accompanied by written medical justification for
				  the service;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 3 - Dental Services › 7 AAC 110.153 - Orthodontic services

Current through May 31, 2024
(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 services rendered by an
				  orthodontist who is enrolled in accordance with
				  7 AAC 110.140, as follows:
(1) limited orthodontic treatment of the primary dentition for a
				  malocclusion that does not involve the entire dentition; the department will
				  pay for limited orthodontic treatment for recipients under 21 years of age;
				  treatment may be directed at the existing problem or at one or more aspects of
				  a larger problem when the decision is made to defer or forego more
				  comprehensive therapy; the prior authorization request must be submitted by the
				  orthodontist and must include
(A) a
				  description of the condition;
(B)
				  a description of the orthodontic appliance;
(C) a scored
Handicapping Labiolingual Deviation (HLD)
				  Index Report
, adopted by reference in
				  7 AAC 160.900, completed and signed by the
				  orthodontist;
(D) a treatment plan
				  for correcting the condition;
(E)
				  panoramic radiographs;
(F) other
				  medical or dental information to support the requested orthodontic treatment,
				  including required extractions or orthognathic surgery; and
(G) an
Orthodontic Referral Oral
				  Health and Hygiene Assessment
, adopted by reference in
				  7 AAC 160.900, completed and signed by the referring
				  dentist;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 3 - Dental Services › 7 AAC 110.155 - Dentist-administered anesthesia and sedation

Current through May 31, 2024
(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 to control
				  pain.
(b) The department will pay
				  for general anesthesia or intravenous sedation required for dental services
				  covered under
				  7 AAC 110.145-7AAC 110.155 if a provider obtains prior
				  authorization from the department. A claim submitted to the department for
				  payment of costs for general anesthesia must be accompanied by written medical
				  justification for the service. Medical justification and prior authorization
				  requests must include documentation substantiating that local anesthesia and
				  sedation under (a) of this section are inadequate to control pain and that the
				  service is required for a patient who meets one of the following conditions:
(1) severe intellectual or developmental
				  disability;
(2) severe physical
				  disability or medically compromised condition;
(3) a prolonged or difficult surgical
				  procedure.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 3 - Dental Services › 7 AAC 110.165 - Advanced practice dental hygienist services

Current through May 31, 2024
(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 under
				  7 AAC 110.145 and
				  7 AAC 110.150 apply to services provided under this
				  section.
(c) Services provided
				  under this section count toward service limits under
				  7 AAC 110.145 and
				  7 AAC 110.150.
(d) Except as specifically excluded under (f)
				  of this section, the department will pay an advanced practice dental hygienist
				  enrolled under
				  7 AAC 110.140 for services that are within the
				  individual's scope of practice and identified in the
Fee Schedule:
				  Advanced Practice Dental Hygienist Services,
adopted by reference in
				  7 AAC 160.900, including
(1) radiographs necessary for routine dental
				  care;
(2) preventive care,
				  including
(A) prophylaxis, including
				  necessary scaling, polishing, and instructions;
(B) topical fluoride application;
				  and
(C) anterior removable space
				  maintainer;
(3) under the
				  direct supervision of a licensed dentist, placement of a restoration into a
				  cavity prepared by a dentist enrolled under this chapter and subsequent
				  carving, contouring, and adjustment of the contacts and occlusion of the
				  restoration; and
(4) non-surgical
				  periodontics and local periodontal therapeutic agents, including treatment of
				  pain or acute infection of supporting tissues of the teeth, including
				  gingivitis, periodontitis, and periodontal abscess.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 4 - Direct-Entry Midwife Services › 7 AAC 110.180 - Direct-entry midwife coverage and limitations

Current through May 31, 2024
(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-entry midwife issued by the jurisdiction in which the
				  individual provides services; if services are provided in this state, the
				  individual must be certified under AS 08.65.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 5 - EPSDT Services › 7 AAC 110.200 - Purpose of EPSDT services

Current through May 31, 2024
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 110.205; and
(2) any necessary health care, diagnostic
				  services, treatment, or other services that meet the requirements of
				  7 AAC 110.210.
(3) additional services if
(A) a provider identified in
				  7 AAC 110.205(a) determines them to be
				  medically necessary; and
(B) they
				  receive prior authorization from the department.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 5 - EPSDT Services › 7 AAC 110.205 - EPSDT screening services

Current through May 31, 2024
(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 of a physician, if
				  the health care practitioner may perform screenings under the health care
				  practitioner's scope of license or certification;
(3) the department;
(4) a tribal health program;
(5) an advanced practice registered
				  nurse;
(6) a rural health clinic or
				  federally qualified health center;
(7) a municipal health department;
(8) a school district.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 5 - EPSDT Services › 7 AAC 110.210 - EPSDT covered services

Current through May 31, 2024
(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
				  identifies a need for that service:
(1)
				  podiatry services under
				  7 AAC 110.500 -
				  7 AAC 110.505;
(2) nutrition services under
				  7 AAC 110.275;
(3) private-duty nursing services under
				  7 AAC 110.520 - 7 AAC 110.535;
(4) hospice care under
				  7 AAC 140.280;
(5) chiropractic services under
				  7 AAC 110.120;
(6) dental services under
				  7 AAC 110.145 -
				  7 AAC 110.155;
(7) physical therapy under
				  7 AAC 115.300 -
				  7 AAC 115.320;
(8) occupational therapy under
				  7 AAC 115.100 -
				  7 AAC 115.120;
(9) speech therapy under
				  7 AAC 115.400 -
				  7 AAC 115.420;
(10) autism services under
				  7 AAC 135.350.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 6 - Family Planning Services › 7 AAC 110.230 - Family planning services

Current through May 31, 2024
(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;
(3) a student health service operated by an
				  educational institution;
(4) a
				  private family planning clinic;
(5)
				  a physician, advanced practice registered nurse, or physician
				  assistant;
(6) a federally
				  qualified health center or rural health clinic.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 7 - Imaging Services › 7 AAC 110.240 - Imaging services

Current through May 31, 2024
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 and
				  488.26 to be in compliance with
				  42 C.F.R.
				  486.100 -
				  486.110, adopted by reference in
				  7 AAC 160.900; or
(2) hold a valid mammography equipment
				  certificate issued by the United States Food and Drug Administration under
				  21 C.F.R.
				  900.11.
Authority:
AS
						47.05.010
AS 47.07.030
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 8 - Nurse Anesthetist Services › 7 AAC 110.250 - Registered nurse anesthetist enrollment and services

Current through May 31, 2024
(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 an active license or certification as a registered nurse
				  anesthetist issued by the jurisdiction in which the individual provides
				  services; if services are provided in this state the individual must hold an
				  active license under AS 08.68 and an active authorization under
				  12 AAC 44.500 -
				  12 AAC 44.560.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 9 - Nutrition Services › 7 AAC 110.270 - Nutrition services provider enrollment requirements

Current through May 31, 2024
To be eligible for payment under 7 AAC 105 - 7 AAC 160 for
					 providing nutrition services, a provider must
(1) be enrolled as a dietitian or
				  nutritionist in accordance with
				  7 AAC 105.210; and
(2) have an active license to practice as a
				  dietitian or nutritionist issued by the jurisdiction in which the individual
				  provides services; if services are provided in this state, the individual must
				  hold an active license to practice under AS 08.38.
Authority:
AS
						47.05.010
AS 47.07.030
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 9 - Nutrition Services › 7 AAC 110.275 - Nutrition services for recipients under 21 years of age

Current through May 31, 2024
(a) The department
				  will pay for outpatient nutrition services provided to a recipient under 21
				  years of age who, consistent with the criteria in (b) of this section, is
				  determined to be at high risk nutritionally by a physician, an advanced
				  practice registered nurse, or another licensed or certified health care
				  practitioner who may order those services within the scope of the
				  practitioner's license or certification.
(b) A recipient under 21 years of age is at
				  high risk nutritionally if the recipient
(1)
				  has a flat growth curve or failure to thrive;
(2) has an atypical height-to-weight ratio,
				  head circumference, or sudden weight change;
(3) has a hemoglobin count of less than 10
				  grams or a hemostat of less than 30 percent;
(4) has a weight of 2,500 grams or less, or a
				  gestation of 36 weeks or less at birth;
(5) has a chronic disease or condition,
				  including diabetes, cystic fibrosis, kidney disease, cancer, colitis,
				  hypertension, diarrhea, constipation, anemia, and infection;
(6) has a congenital anomaly or genetic
				  disorder, including cleft lip or palate, Down syndrome, spina bifida, heart
				  disease, and phenylketonuria;
(7)
				  is pregnant or breast-feeding; or
(8) has a growth problem with a nutritional
				  condition that requires a special formula or diet.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 9 - Nutrition Services › 7 AAC 110.280 - Nutrition services for pregnant women

Current through May 31, 2024
(a) The department
				  will pay for outpatient nutrition services provided to a recipient who is
(1) pregnant;
(2) consistent with the criteria in (b) of
				  this section, determined to be at high risk nutritionally by
(A) a physician, an advanced practice
				  registered nurse, or a physician assistant who may order those services within
				  the scope of the practitioner's license or certification; or
(B) a licensed dietitian or nutritionist
				  employed by a hospital or the state's Special Supplemental Nutrition Program
				  for Women, Infants, and Children (WIC) under  42 U.S.C. 1786.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 10 - Physician Services › 7 AAC 110.400 - Physician services provider enrollment requirements

Current through May 31, 2024
(a) To be eligible
				  for payment under 7 AAC 105 - 7 AAC 160 for providing physician services, the
				  provider must
(1) be enrolled as a physician
				  in accordance with
				  7 AAC 105.210; and
(2) have an active license to practice
				  medicine or osteopathy issued by the jurisdiction in which the physician
				  provides services; if services are provided in this state the individual must
				  hold an active license under AS 08.64.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 10 - Physician Services › 7 AAC 110.405 - Physician services coverage and limitations

Current through May 31, 2024
(a) Subject to
				  7 AAC 110.400 -
				  7 AAC 110.455, the department will pay a physician who
				  meets the requirements of
				  7 AAC 110.400 for the following services provided within
				  the scope of the physician's license to practice medicine or osteopathy:
(1) any physician services and supplies
				  necessary for diagnosing and treating illness and injury for which a payment
				  rate has been established by the department that meets the requirements of
				  7 AAC 145.020;
(2) preventive health screening and treatment
				  provided as part of the EPSDT program under
				  7 AAC 110.200 -
				  7
				  AAC 110.215;
(3) physician services provided in a nursing
				  facility in accordance with
				  7 AAC 110.410;
(4) sterilization performed by a physician in
				  accordance with
				  7 AAC 110.415;
(5) a hysterectomy performed by a physician
				  in accordance with
				  7 AAC 110.420;
(6) speech-language pathology services, if
				  medically necessary;
(7) hearing
				  services, if medically necessary;
(8) a complete vision examination, including
				  a check of refractive state, if a complete vision examination is clinically
				  indicated and the recipient has significant difficulties or complaints related
				  to vision;
(9) anesthesia, if
				  billed in accordance with the American Society of Anesthesiologists'
Relative Value Guide
, adopted by reference in
				  7 AAC 160.900;
(10) clinical intervention counseling
				  associated with smoking cessation for no more than 10 sessions per calendar
				  year.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 10 - Physician Services › 7 AAC 110.410 - Physician services in a nursing facility

Current through May 31, 2024
(a) For a physician
				  visit to a recipient living in a nursing facility, the department will not pay
				  for more than
(1) one initial evaluation and
				  management visit per recipient stay; and
(2) one subsequent or established care visit
				  per recipient per 30-day period.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 10 - Physician Services › 7 AAC 110.415 - Sterilization by a physician

Current through May 31, 2024
(a) The department
				  will pay for a sterilization performed by a physician only if
(1) the recipient is 21 years of age or
				  older;
(2) the procedure is for
				  family planning purposes;
(3) the
				  recipient has, by signature, given informed consent using the form provided by
				  the department;
(4) except as
				  provided in (b) of this section, the procedure was performed no sooner than 30
				  days, and no later than 180 days, after the date the recipient signed the
				  consent form;
(5) the provider
				  signs the consent form before the procedure; and
(6) the consent form is attached to the
				  provider claim.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 10 - Physician Services › 7 AAC 110.420 - Hysterectomy by a physician

Current through May 31, 2024
(a) The department
				  will pay for a hysterectomy performed by a physician if the
(1) department has given prior
				  authorization;
(2) procedure is
				  performed for medical reasons;
(3)
				  recipient has given her informed consent in writing using the form provided by
				  the department or a form provided by the physician that includes the same
				  information;
(4) consent from was
				  signed by the recipient before surgery, unless the provider who performs the
				  surgery certified in writing that
(A) the
				  recipient was sterile before the hysterectomy and states the cause of the
				  sterility; or
(B) the hysterectomy
				  was performed under a life-threatening emergency, that is described by the
				  provider, and getting prior consent from the recipient was not possible;
				  and
(5) consent form is
				  attached to the provider claim.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 10 - Physician Services › 7 AAC 110.425 - Obstetrical care by a physician

Current through May 31, 2024
The department will pay for routine obstetrical care
					 provided by a physician. A physician may not submit a claim for routine global
					 obstetrical care if the recipient does not have third-party health insurance
					 available.
Authority:
AS
						47.05.010
AS 47.07.030
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 10 - Physician Services › 7 AAC 110.430 - Office medical supplies

Current through May 31, 2024
Office medical supplies routinely associated with physician
					 office visits and procedures are included in the practice cost portion of the
					 resource-based relative value scale (RBRVS) fee schedule developed under
					 7 AAC 145.050 and are not paid
					 separately.
Authority:
AS
						47.05.010
AS 47.07.030
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 10 - Physician Services › 7 AAC 110.435 - Physician laboratory services

Current through May 31, 2024
(a) The department
				  will pay for laboratory services provided by a physician in the physician's own
				  laboratory if the physician holds a CMS Clinical Laboratory Improvement
				  Amendments (CLIA) certificate of waiver under
				  42 C.F.R.
				  493.35 -
				  493.37 or a registration
				  certificate under 42 C.F.R.
				  493.43 -
				  493.45.
(b) A physician using the services of an
				  independent laboratory must request services for a recipient in the same manner
				  that services are requested for a private patient.
(c) An independent laboratory enrolled in
				  accordance with
				  7 AAC 105.210 may submit a claim directly to the
				  department.
Authority:
AS
						47.05.010
AS 47.07.030
AS
						47.07.040
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 10 - Physician Services › 7 AAC 110.440 - Physician radiology and imaging services

Current through May 31, 2024
(a) The department
				  will pay for diagnostic and follow-up x-rays without prior approval by the
				  department, but films shall be made available to the department on
				  request.
(b) The department will
				  not pay for radiologic contrast material separate from coverage for an x-ray
				  except for low osmolar contrast material (LOCM) used in intrathecal,
				  intravenous, and intra-arterial injections for a recipient with
(1) a history of previous adverse reaction to
				  contrast material other than a sensation of heat, flushing, or a single episode
				  of nausea or vomiting;
(2) a
				  history of asthma or allergy;
(3)
				  significant cardiac dysfunction, including recent or imminent cardiac
				  decompensation, severe arrhythmias, unstable angina pectoris, recent myocardial
				  infarction, or pulmonary hypertension;
(4) general severe debilitation; or
(5) sickle cell disease.
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 10 - Physician Services › 7 AAC 110.445 - Mental health services by a physician

Current through May 31, 2024
(a) Subject to the
				  limitations identified in this section, the department will pay for mental
				  health services provided by a physician if those services are
(1) medically necessary;
(2) rendered directly by that physician;
				  and
(3) specified in a treatment
				  plan that meets the requirements of
				  7 AAC 135.120(a) (1) - (5) and
				  (b).
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 10 - Physician Services › 7 AAC 110.450 - Surgical assistant

Current through May 31, 2024
(a) The department will pay for a physician,
				  an advanced practice registered nurse, or a physician assistant acting as a
				  surgical assistant. A second surgical assistant will be paid at the same rate
				  as the first surgical assistant if the primary surgeon submits a written
				  explanation acceptable to the department that justifies the need for the second
				  surgical assistant.
(b) The
				  department will not pay a licensed practical nurse, a registered nurse, or an
				  intern therefore acting as a surgical assistant apart from the payment made to
				  the surgeon.
Authority:
AS
						47.05.010
AS
						47.07.030
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 10 - Physician Services › 7 AAC 110.455 - Physician assistant enrollment and services

Current through May 31, 2024
(a) For the
				  department to provide payment under
				  7 AAC 145.200, a physician assistant who furnishes
				  services directly to a recipient in the state must separately enroll with the
				  department as a rendering provider under
				  7 AAC 105.210 and
(1)
				  unless the physician assistant is a federal employee described in
				  7 AAC 105.200(c), must
(A) have an active license to practice in the
				  state as a physician assistant under
				  12 AAC 40.400 -
				  12 AAC 40.405;
(B) submit a copy of the collaborative plan
				  with the supervising physician required under
				  12 AAC 40.410; and
(C) notify the department of any changes to
				  the collaborative plan by submitting a copy of the new plan;
Alaska Administrative Code › Title 7 - Health and Social Services › Part 8 - Medicaid Coverage and Payment › Chapter 110 - Medicaid Coverage; Professional Services › Article 11 - Podiatry Services › 7 AAC 110.500 - Podiatry services provider enrollment requirements

Current through May 31, 2024
(a) To be eligible
				  for payment under 7 AAC 105 - 7 AAC 160 for providing podiatry services, a
				  provider must
(1) be enrolled as a podiatrist
				  in accordance with
				  7 AAC 105.210; and
(2) have an active license to practice
				  podiatry issued by the jurisdiction in which the podiatrist provides services;
				  if services are provided in this state the podiatrist must hold an active
				  license under AS 08.64.