This regulation establishes general Medicaid program participation rules for Alaska, covering conditions for covered and noncovered services, prior authorization requirements, out-of-state service coverage, and disaster emergency provisions. It applies broadly to all Medicaid providers and recipients and does not license or set operating standards for any specific behavioral health, IDD, or foster care facility type. Psychiatric hospitals and residential psychiatric treatment centers are mentioned only in the context of out-of-state provider approval and prior authorization cross-references, not as facilities governed by this chapter.
View official source7 AAC 105.100. Covered services. 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 prescribed by a provider authorized to order or prescribe that service under applicable law; (4) is provided by a person who is enrolled as a Medicaid provider or rendering provider under 7 AAC 105.210 , or otherwise eligible to receive payment for services under 7 AAC 105 - 7 AAC 160 ; (5) is medically necessary as determined by criteria established under 7 AAC 105 - 7 AAC 160 or by the standards of practice applicable to the provider; (6) has received prior authorization from the department, if prior authorization is required under 7 AAC 105 - 7 AAC 160 ; and (7) is not specifically excluded as a noncovered service under 7 AAC 105 - 7 AAC 160 . 7 AAC 105.110. Noncovered services. 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 that is not identified in a screening required under 7 AAC 110.205 ; (2) not properly prescribed or medically necessary in accordance with criteria established under 7 AAC 105 - 7 AAC 160 or by standards of practice applicable to the prescribing provider; (3) incurred for an evaluative or periodic checkup, examination, or immunization (A) that is in connection with the participation, enrollment, attendance, or accomplishment of a program or activity unrelated to the recipient's physical or mental health or rehabilitation; or (B) unless it is (i) an adult preventive service covered under 7 AAC 110.800 ; (ii) part of an EPSDT screening; or (iii) required by the department for the purpose of determining eligibility for Medicaid; (4) for or in connection with cosmetic therapy or plastic or cosmetic surgery, including rhinoplasty, nasal reconstruction, excision of keloids, augmentation mammoplasty, silicone or silastic implants, facioplasty, osteoplasty (prognathism and micronathism), dermabrasion, skin grafts, and lipectomy; however, coverage is available if required for the following corrective actions if performed within the normal course of treatment or otherwise beginning no later than one year after birth or the event that caused the need for the corrective action: (A) repair of an injury; (B) improvement of the functioning of a malformed body member; (C) correction of a visible disfigurement that would materially affect the recipient's acceptance in society; (5) a nonmedical charge imposed by a recipient's friend or relative; (6) for a person who is in the custody of federal, state, or local law enforcement, unless the person is (A) an inpatient in a medical institution; or (B) a justice-involved youth who is eligible for and receiving covered services under 42 U.S.C. 1396a(a)(84)(D); (7) for an experimental or investigational service, except for covered routine patient costs associated with clinical trials specified in 42 U.S.C. 1396d(gg)(1), adopted by reference in 7 AAC 160.900 ; for the purposes of this paragraph, an experimental or investigational service for which the department will not pay includes one (A) that is in a phase I or II clinical trial as defined in the United States Department of Health and Human Services, National Institutes of Health, Glossary of Terms for Human Subjects Protection and Inclusion Issues, adopted by reference in 7 AAC 160.900 ; (B) for which inadequate available clinical or preclinical data exists to provide a reasonable expectation that the proposed service is at least as safe and effective as one not under experiment or investigation; (C) for which an expert has issued an opinion that additional information is needed to assess the safety or efficacy of the proposed service; (D) for which final approval from the appropriate governmental body has not been granted for the specific indications for which the use of the service is being proposed; however, if a drug has received final approval from the United States Food and Drug Administration (FDA) for any indication, final approval is not required for the specific indication for which use is being proposed if (i) the prescription or order was issued by a licensed health care provider within the scope of the provider's license; (ii) prior authorization was obtained from the department if required under 7 AAC 105 - 7 AAC 160 ; or (iii) the condition being treated with the drug is not otherwise excluded as a use of the drug; or (E) whose use is not in accordance with customary standards of medical practice; (8) for missed appointments; however, the provider may charge the recipient; (9) for interpreter services; (10) for infertility services; (11) for impotence therapy and services; (12) repealed 7/25/2021; (13) for sterilization for recipients under 21 years of age and hysterectomies performed solely for sterilization purposes; (14) for nonsurgical weight reduction or maintenance treatment programs and products; (15) for nonmedical fitness maintenance centers and services; (16) for educational services or supplies that are separately identifiable in the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services' (CMS) Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900 ; (17) an alternative therapy or other service including acupuncture, homeopathic or naturopathic remedy, or Ayurvedic medicine; (18) an outpatient drug for which payment under the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services' drug rebate program established in 42 U.S.C. 1396r-8 is not available; (19) for which the recipient does not meet the eligibility requirements for that service under 7 AAC 100 ; or (20) after the recipient's date of death. 7 AAC 105.120. Out-of-state covered services. (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 department is able to verify one of the following situations: (A) the recipient requires a medical service that is not available in this state or the provision of that service out of state is more cost-effective; (B) the medical service is needed due to a medical emergency while a recipient is out of state and the recipient's health would be endangered if the recipient were required to travel to this state for the needed medical service; (C) laboratory specimens are sent out of state because (i) the laboratory service is not offered in this state; (ii) the laboratory service is more readily available out of state; or (iii) to have the laboratory work performed out of state is more cost-effective. (b) The department may pay an out-of-state provider for a service provided to a recipient from this state that meets the requirements of (a) of this section if the provider (1) is enrolled in the Medicaid program in this state; (2) is enrolled in the Medicaid program in the jurisdiction where the service is provided; and (3) possesses the appropriate license in the other jurisdiction to provide the required service. (c) The department may deny a request for a service provided out of state that requires prior authorization by the department if the requirements of (a) of this section are not met. (d) An inpatient psychiatric hospital, psychiatric facility, and a residential psychiatric treatment center may be approved by the department as a provider, if the department determines that a need exists for the service under (a)(2) of this section. 7 AAC 105.130. Services requiring prior authorization. (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 health care service for which prior authorization is specifically required under 7 AAC 105 - 7 AAC 160 ; (3) a service that exceeds an annual or periodic service limitation established in 7 AAC 105 - 7 AAC 160 ; (4) an item of durable medical equipment, supplies, or hearing items identified in 7 AAC 105 - 7 AAC 160 as requiring prior authorization; (5) respiratory therapy; (6) home health care services under 7 AAC 125.300 - 7 AAC 125.399 ; (7) home infusion therapy services; (8) private-duty nursing services; (9) hospice care services; (10) magnetic resonance imaging (MRI), magnetic resonance angiogram (MRA), single-photon emission computerized tomography (SPECT), and positron emission tomography (PET); (11) an inpatient or outpatient procedure or diagnosis, regardless of the length of stay, identified in the Select Diagnoses and Procedures Pre-certification List, adopted by reference in 7 AAC 160.900 ; (12) an inpatient hospital continued stay that exceeds an applicable limitation in 7 AAC 140.320 on length of hospitalization, except that if the department reimburses an inpatient hospital under the Diagnosis Related Groups (DRG) payment rate methodology under 7 AAC 150.250 , the hospital is exempt from this requirement; (13) a prescription drug identified on the Alaska Medicaid Prior-authorized Medications List, adopted by reference in 7 AAC 160.900 ; (14) an inpatient psychiatric hospital admission in accordance with 7 AAC 140.360 ; (15) a residential psychiatric treatment center admission or continued stay in accordance with 7 AAC 140.405 ; (16) an administrative-wait or swing-bed stay at a general acute care hospital; (17) a long-term care facility admission or continued stay; (18) home and community-based waiver services under 7 AAC 130 ; (19) personal care services under 7 AAC 125.010 - 7 AAC 125.199 ; (20) behavioral health services identified in 7 AAC 135 as requiring prior authorization; (21) surgical procedures to alter a recipient's body to conform to the recipient's gender identity; (22) therapy services identified in 7 AAC 115.110 , 7 AAC 115.210 , 7 AAC 115.310 , and 7 AAC 115.410 as requiring prior authorization. (b) Except as provided in 7 AAC 140.320 , failure to obtain the required prior authorization may result in nonpayment, regardless of the eligibility of the recipient or the appropriateness of the services. (c) For prior authorization, factors that the department will consider include the service's medical necessity, clinical effectiveness, cost-effectiveness, and likelihood of adverse effects, as well as service-specific requirements in 7 AAC 105 - 7 AAC 160 . The department may place minimum or maximum quantities allowed of a specific service, may require other services before the recipient receives the requested service, or may require prior authorization for other services, as necessary (1) for the protection of the public health, safety, and welfare; (2) to prevent waste, fraud, and abuse of the Medicaid program; or (3) to maintain the financial integrity of the department and the Medicaid program. (d) The department may pay for a service under (a) of this section without prior authorization if prior authorization was not possible before the service was provided or a claim for payment is being processed after the service was provided following determination of a recipient's retroactive eligibility under 7 AAC 100.072 . 7 AAC 105.140. Covered services during declared disaster emergency. (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 disaster emergency declaration for the state or a region within the state under AS 26.23.020 ; (2) the federal government issues a related disaster declaration or declaration of national emergency for the state or a region within the state under 42 U.S.C. 5121 - 5207 (Stafford Disaster Relief and Emergency Assistance Act) or 50 U.S.C. 1601 - 1651 (National Emergencies Act) and the Secretary of the United States Department of Health and Human Services invokes authority under 42 U.S.C. 1320b-5(b) (sec. 1135(b) of the Social Security Act), with respect to the secretary's declaration of a public health emergency as described under 42 U.S.C. 1320b-5(b) and (g)(1), to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Social Security Act as a result of the disaster declaration; and (3) the state either (A) applies for and receives an approved disaster relief state plan amendment, authorized under 42 U.S.C. 1320b-5, based on the disaster emergency declaration, to make the changes provided for in this section; or (B) has existing state plan authority from CMS to exercise the provisions of (b) of this section during a declared disaster emergency. (b) If the conditions listed in (a) of this section are met, the department may (1) for covered outpatient drugs under 7 AAC 105 - 7 AAC 160 , (A) extend the fill duration authorization under 7 AAC 120.112 (4) from a 34-day to 68-day supply; (B) increase the professional dispensing fee rates for in-state claims under 7 AAC 145.410 (a)(1) and (2) by up to $2.50; (C) increase the professional dispensing fee reimbursement frequency under 7 AAC 145.410 (a)(1) and (2) to not more than once every 14 days; (D) allow ingredient reimbursement at actual acquisition cost if the actual acquisition cost is above the lowest determined cost under the formula provided in 7 AAC 145.400 and the provider maintains proof of the actual acquisition cost of the drug consistent with 7 AAC 105.230 , substantiated by an unaltered invoice under 7 AAC 105.240 ; (E) waive the cost-sharing amounts eligible recipients are required to pay under 7 AAC 105.610 (a)(4), if the service is related to screening for, diagnosing, or treating the condition at issue in a public health emergency; or (F) waive the requirement under 7 AAC 145.400 (j) that a provider return to the pharmacy covered but unused outpatient drugs dispensed in unit doses to a recipient in a long-term care facility, if a public health emergency includes a risk of infection control; (2) for vaccines authorized by the Federal Drug Administration in response to a public health emergency, reimburse providers under 7 AAC 110.750 , consistent with 7 AAC 145.020 ; or (3) reimburse a registered pharmacist acting within the scope of the person's practice under 12 AAC 52 for services consistent with 7 AAC 105 - 7 AAC 160 and with this subsection during the disaster emergency, including providing testing and other services authorized by a standing order of the chief medical officer when not explicitly defined within the scope of the person's practice. (c) Reimbursements provided for under this section may be requested or disbursed after a declaration of emergency has expired, within standard timely filing under 7 AAC 145.005 , for services provided during the emergency. 7 AAC 105.200. Eligible Medicaid providers. (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 person provides services, to practice as (A) a physician, including an osteopath; (B) a podiatrist; (C) a dentist; (D) an optometrist; (E) a chiropractor; (F) a pharmacist or retail pharmacy; (G) a physical therapist; (H) an occupational therapist; (I) an audiologist; (J) a speech-language pathologist; (K) an advanced practice registered nurse; (L) a direct-entry midwife; (M) a dietitian; (N) a nutritionist; (O) a psychologist; (P) a hearing aid dealer; (Q) a registered nurse anesthetist; or (R) a behavior analyst; (S) a clinical social worker; (T) a marital and family therapist; (U) a licensed professional counselor; (V) a licensed dental hygienist who holds an advanced practice permit issued by the Board of Dental Examiners under AS 08.32.125 ; (2) a facility licensed under AS 47.32 , or under the laws of the jurisdiction in which it provides services, to operate as (A) a general acute care hospital or inpatient psychiatric hospital; (B) a long-term care facility; (C) a home health agency; (D) a rural health clinic; (E) an ambulatory surgical center; (F) a hospice care agency; (G) a residential psychiatric treatment center for persons under 22 years of age; or (H) an intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID); (I) a free-standing birth center; (3) a company or individual not excluded in (b) of this section, supplying (A) medical transportation, ambulance services, oxygen, or eyeglasses; (B) under 7 AAC 120.200 - 7 AAC 120.399 , durable medical equipment, medical supplies, prosthetics, orthotics, noncustomized-fabricated orthotics, respiratory therapy, enteral and oral nutritional products, or home infusion therapy; or (C) items paid under 7 AAC 130.305 as specialized medical equipment and supplies; (4) a provider of EPSDT screening services under 7 AAC 110.205 ; (5) a facility providing services for end-stage renal disease; (6) a personal care agency; (7) a home and community-based waiver services provider, including a provider of environmental modification services under 7 AAC 130.300 ; (8) a care coordination agency provider, as defined in 7 AAC 130.319 ; (9) a residential supported-living services provider, as defined in 7 AAC 130.319 ; (10) a federally qualified health center (FQHC); (11) a tribal health program; (12) a provider of in-state freestanding or portable x-ray services; (13) a provider of behavioral health rehabilitation services under 7 AAC 135.010 (c) for a child experiencing a severe emotional disturbance as described in 7 AAC 135.065 ; (14) a private-duty nursing agency; (15) a school district providing a Medicaid-covered service to a Medicaid recipient; (16) an independent laboratory; (17) an outpatient therapy center; (18) a provider of family planning services; (19) a provider of targeted case management services; (20) a community behavioral health services provider; (21) a mental health physician clinic; (22) repealed 10/1/2011. (b) Each of the following providers must enroll with the department as a rendering provider, but payment for those services will be made through the rendering provider's supervising health care provider enrolled under this section: (1) a licensed physician assistant; (2) a licensed physical therapy assistant; (3) a licensed occupational therapy assistant; (4) a registered speech-language pathologist assistant; (5) a registered respiratory therapist; (6) a certified respiratory therapy technician; (7) a personal care assistant; (8) a care coordinator; (9) a licensed practical nurse who provides direct services to a recipient as an employee of a private-duty nursing agency; (10) a licensed registered nurse who provides direct services to a recipient as an employee of a private-duty nursing agency; (11) a licensed assistant behavior analyst under 7 AAC 135.300 ; (12) an autism behavior technician under 7 AAC 135.300 . (c) Notwithstanding any other provision of 7 AAC 105 - 7 AAC 160 , and if the employee has an active license from a jurisdiction in the United States, a health care provider who is an employee of the federal government assigned to a tribal health program is exempt from any requirement in 7 AAC 105 - 7 AAC 160 that the provider be licensed, certified, or registered by this state to be eligible under this section. (d) Notwithstanding any other provision of 7 AAC 105 - 7 AAC 160 , a hospital, clinic, or other type of health care facility that is operated by a tribal health program is exempt from a requirement in 7 AAC 105 - 7 AAC 160 that the provider be licensed or certified by this state to be eligible under this section. (e) If a rendering provider identified in (b) of this section is an employee of or under contract with an enrolled tribal health program, that tribal health program is the supervising health care provider of that rendering provider for the purposes of receiving payment under 7 AAC 105 - 7 AAC 160 . 7 AAC 105.210. Provider enrollment requirements. (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 and provider information submission agreement on forms provided by the department; (2) must verify that the provider meets all other applicable requirements of 7 AAC 105 - 7 AAC 160 and all applicable federal and state licensing and certification requirements; (3) must comply with all federal and state laws as they apply to providing health care or related services to Medicaid recipients in this state, including laws related to recipient confidentiality, electronic transactions, and civil rights; (4) must assume responsibility for all information and claims submitted to the department by that provider or that provider's billing agent; (5) must agree to submit claims in the form or format required by the department for claim submission; (6) must comply with the requirements of AS 47.05.300 - 47.05.390 and 7 AAC 10.900 - 7 AAC 10.990 (barrier crimes and conditions; background checks), if applicable to that provider type; and (7) if an out-of-state provider, must (A) verify enrollment in the Medicaid program in the jurisdiction in which services are provided if Medicaid enrollment is available for that type of provider in that jurisdiction; or (B) provide documentation from the jurisdiction in which the provider provides services that Medicaid enrollment is not available in the jurisdiction for that type of provider. (c) A provider who is practicing under a temporary or locum tenens permit, license, or authorization issued under AS 08 , and who is substituting for another provider, being evaluated for permanent employment, or temporarily employed by a facility while it attempts to fill a vacant position must enroll as required in (a) and (b) of this section. (d) The department may disenroll a provider who has not submitted a claim for at least 18 months. (e) The department may enroll a provider with a retroactive effective date of enrollment of up to one year if the provider (1) meets the requirements of this section; and (2) provided services covered under 7 AAC 105 - 7 AAC 160 to a Medicaid recipient during the immediately preceding year for which the provider has not been paid. (f) Not later than 30 days after the change, and on a form specified by the department, an enrolled provider shall notify the department of any change to the information submitted under (b)(1) of this section. 7 AAC 105.220. Provider responsibilities. (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 recipients in this state, including laws related to recipient confidentiality, electronic transactions, scope of practice, and civil rights; (2) submit claims in the form or format required by the department for claim submission; and (3) cooperate in reports, surveys, reviews, or audits conducted by the department. (b) A provider shall retain records necessary to disclose fully to the department the extent of services provided to recipients. Information regarding a payment must be made available, upon request, to state and federal personnel of agencies associated with the Medicaid program. (c) A provider shall allow on-site inspection by authorized representatives of both state and federal agencies associated with the Medicaid program. (d) A provider is responsible for claims submitted or certified by an authorized representative. (e) A provider's or agent's endorsement of a check received from the department certifies that the claim for which the check is payment is true and accurate unless written notice of an error is sent by the provider to the department no more than 30 days after the date that the check is negotiated. (f) In accordance with 7 AAC 105.400 , a provider must refund to the department any paid claim that the department finds, after post-payment review under 7 AAC 160.100 - 7 AAC 160.140 , does not meet the requirements of 7 AAC 105 - 7 AAC 160 . 7 AAC 105.230. Requirements for provider records. (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's financial, clinical, and other records meets the requirements of this section; and (3) may not submit a claim to the department for payment for services unless the provider's records are kept and maintained in accordance with this section. (b) A provider's record must identify recipient information for each recipient including the (1) name of the recipient receiving treatment; (2) specific services provided; (3) extent of each service provided; (4) date on which each service was provided; and (5) individual who provided each service. (c) A provider's record must identify financial information for each recipient including (1) the charge for each service provided; (2) each payment source pursued; (3) the date and amount of all debit and credit billing actions for each date of service provided; and (4) the amounts billed and paid. (d) A provider shall maintain a clinical or therapeutic record in accordance with professional standards applicable to the provider, for each recipient. The clinical record must include (1) information that identifies the recipient's diagnosis; (2) information that identifies the medical need for each service; (3) identification of each service, prescription, supply, or plan of care prescribed by the provider; (4) identification of prescription drugs dispensed in accordance with 7 AAC 120.100 - 7 AAC 120.140 ; (5) start and stop times for time-based billing codes; (A) a provider may only bill for a unit of service if the actual direct service time spent is in excess of 50 percent of the time value of the procedure code billed; (B) direct service time associated with a particular procedure code shall be calculated in the aggregate by the direct service provider for each date of service when determining the appropriate number of units that may be billed; (C) a provider may not use pre-populated clinical notes or time-sheets to document actual start and stop times; (D) a provider may not bill for services without proper start and stop times documentation; (E) the use of documentation that does not specify both start and stop times will result in an overpayment; (F) the following table shall be used when billing for time-based billing codes under this section and identifies the appropriate number of units to bill using a 15-minute time-based code: UnitsNumber of Minutes of Direct Service Time1>= 8 minutes through 22 minutes2>= 23 minutes through 37 minutes3>= 38 minutes through 52 minutes4>= 53 minutes through 67 minutes5>= 68 minutes through 82 minutes6>= 83 minutes through 97 minutes7>= 98 minutes through 112 minutes8>= 113 minutes through 127 minutesThe pattern remains the same for direct service times in excess of 2 hours. (G) the following services may be billed on the same day as any other residential or inpatient service not already contraindicated when the recipient is discharged from a residential or inpatient service and admitted into a 23-hour crisis observation and stabilization service, crisis residential and stabilization service, or residential or inpatient service on the same day: (i) 23-hour crisis observation and stabilization services; (ii) crisis residential and stabilization services; (iii) residential or inpatient services; (6) annotated case notes identifying each service or supply delivered; (A) the case notes must be dated and either signed or initialed by the individual who provided each service; (B) for electronic records, an electronic signature that complies with the requirements of AS 09.80 (Uniform Electronic Transactions Act) satisfies the signature requirement under this section; and (7) except for facilities identified in 7 AAC 12.990 (26), all records maintained contemporaneously with the service provided; for purposes of this section, contemporaneous record keeping means documentation is done not later than 14 days after the service ends; a provider may not bill for services for which records were not kept contemporaneously as required under this section. (e) A provider shall retain a recipient's records described in (b) - (d) of this section for which services have been billed to the department for at least seven years from the date the service is provided. The duty of the provider set out in this subsection applies to a provider even if the provider's business is sold or transferred, or is no longer operating. If a provider ceases business, the provider shall notify the department how the department can access Medicaid recipient records in the future. (f) A provider who maintains all or part of the provider's records in an electronic format shall ensure that the data required to be maintained by this section is available and accessible under this chapter or if requested under 7 AAC 105.240 (a). The electronic records include the use of an electronic visit verification system required under 7 AAC 125.070 , 7 AAC 125.350 , 7 AAC 127.053 , and 7 AAC 130.285 . A provider's electronic data storage system must (1) comply with P.L. 104-191 (Health Insurance Portability and Accountability Act); (2) protect against unauthorized modification; and (3) identify the creator and date of initial data entry and any modification. (g) Nothing in this section prohibits the use of an electronic health record or electronic visit verification system that generates prepopulated demographic data. (h) A provider may not submit a claim to the department for a service if a provider does not maintain records in compliance with this chapter, including records that must be maintained contemporaneously under this section. (i) Documentation of start and stop times as set out in this section is not required for evaluation and management codes, but documentation must be maintained in accordance with professional guidance as adopted by reference in 7 AAC 160.900 (a). (j) Any claim submitted for reimbursement for which the provider fails to maintain documentation required by this section is considered an overpayment and subject to recoupment under 7 AAC 105.260 . 7 AAC 105.240. Request for records. (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 105.230 (b) - (d). The provider shall provide the records that are the subject of the request (1) to the person making the request at the address specified in the request; (2) no later than the deadline for production of the record that is specified in the request, unless the deadline is modified or extended under (c) of this section; (3) without charge; and (4) in the form stated in the request. (b) When a request for records is made under (a) of this section, (1) the provider may provide a copy of the record unless the request specifies that the original record must be provided; and (2) the person making the request may review, copy, or take custody of the original record. (c) Upon the written request of a provider, the department may modify or extend the time period for production of the record. (d) If, in response to a request for a record under (a) of this section, the provider does not produce the record on or before the deadline specified in the request or the deadline modified or extended under (c) of this section, (1) for purposes of an audit, program review, or investigation, the person making the request may consider the record to be nonexistent; and (2) the department may deny a payment or may initiate a recoupment, another procedure to recover an overpayment, or sanctions under 7 AAC 105.410 based on a determination of the record's nonexistence under (1) of this subsection. 7 AAC 105.250. Payment from other sources. 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 the department's liability, or the provider will be subject to recoupment under 7 AAC 105.260 . 7 AAC 105.260. Recouping an overpayment. (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 service not covered under 7 AAC 105 - 7 AAC 160 ; (4) for a service not authorized under the provider's current provider agreement; (5) for a service paid for by another source, or a service eligible for payment by another source; (6) in an amount the provider or the department identifies as an overpayment; (7) in excess of the amount due because of an error or omission of an automated claims processing system; (8) incorrectly for services that do not meet standards established for payment of services; (9) who is not an enrolled Medicaid provider; (10) for a service already paid by the department; (11) for a service provided to a recipient ineligible for Medicaid under AS 47.07 and 7 AAC 100 ; (12) for a service provided to a recipient eligible for Medicaid under AS 47.07 and 7 AAC 100 , but ineligible for the service billed to the department; (13) in excess of the amount due because of the billing practices of the provider; or (14) for a service that was not rendered. (b) The department may (1) recoup an overpayment from a provider, without notice to the provider other than as provided by (c) of this section, by reducing future payments to the provider until the overpaid amount has been offset; or (2) arrange with the provider the terms of the provider's repayment of the overpayment. (c) Before the department (1) recoups an overpayment more than 120 days after the date of the overpayment under (b)(1) of this section, the department will notify the provider in writing at least 60 days before recoupment of the overpayment begins; or (2) recoups an overpayment under (b)(2) of this section, the department will notify the provider in writing at least 60 days before recoupment of the overpayment begins. (d) In the notice under (c) of this section, the department will include (1) the reason for the recoupment; (2) the amount of the overpayment that the department will recoup; and (3) notice of the provider's right to an appeal under 7 AAC 105.270 . (e) If, following receipt of a notice under (c) of this section, the provider discontinues billing the department for Medicaid services, the department will send a written demand to the provider for repayment of the balance of the overpayment. (f) This section does not apply to (1) actions under 7 AAC 105.400 - 7 AAC 105.490 , or bankrupt or out-of-business providers; (2) recoupment that is based solely on a prospective payment rate under 7 AAC 150 ; (3) recoupment actions identified in an audit under 7 AAC 160.100 - 7 AAC 160.130 ; (4) recoupment actions identified in an independent certified audit under 7 AAC 150.180 (l) with respect to a hospital receiving payments as a disproportionate share hospital (DSH). 7 AAC 105.270. First-level provider appeal. (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 appeal of the denied or reduced claim or service that specifies the basis upon which the decision is challenged and includes any supporting documentation; (2) a copy of the original denied or reduced claim and attachments; (3) a copy of the remittance advice relating to the denied or reduced claim; and (4) if applicable, an adjustment or void request completed by the provider correcting the information submitted with the original claim. (b) In an appeal under (a) of this section of a decision that denied the payment of a claim based on the provider's failure to file the claim before the billing deadline under 7 AAC 145.005 (c), the department's designee shall (1) approve the appeal and pay the maximum amount allowed under 7 AAC 105 - 7 AAC 160 if the department's designee determines that (A) the department committed an error on a claim previously submitted by the provider for the same service to the same recipient on the same day; (B) the claim was timely filed but not processed; or (C) the provider has good cause under 7 AAC 105.280 (h) for the provider's failure to submit the claim before the billing deadline under 7 AAC 145.005 (c); or (2) deny the provider's appeal if the department's designee determines that the claim was not timely filed. (c) A provider may request a first-level appeal of a noncertification of hospital admission or length of stay that, under 7 AAC 105 - 7 AAC 160 , requires prior approval by a quality improvement organization, if no later than 180 days after the date of the noncertification of the hospital admission or length of stay notice, a provider submits to the quality improvement organization (1) a written request for a first-level appeal that specifies the basis upon which the decision is challenged and includes any supporting documentation; (2) a complete copy of the recipient's medical records that support the hospital admission or length of stay and any other supporting documentation; and (3) a copy of the original noncertification notice and attachments. (d) A provider may request a first-level appeal of a decision that denied or reduced prior authorization under 7 AAC 105 - 7 AAC 160 if, no later than 180 days after the date of that decision, the provider submits a written request for a first-level appeal to the department's designee. This subsection does not include prior authorizations for services that require certification by a quality improvement organization. The appeal must (1) specify the basis upon which the decision is challenged and include any supporting documentation; and (2) include a copy of the original notice of denial of or reduced prior authorization. (e) A provider may request a first-level appeal of a noncertification decision regarding a service that, under 7 AAC 105 - 7 AAC 160 , requires certification by a quality improvement organization in order to obtain prior authorization. The provider must submit the appeal to the quality improvement organization no later than 180 days after the date of the noncertification decision. The request for a first-level appeal must be in writing and include (1) the basis upon which the decision is challenged and any supporting documentation; and (2) a copy of the original noncertification notice and attachments. (f) A provider may request a first-level appeal of a recoupment of overpayment notice issued under 7 AAC 105.260 (c). The provider must submit the appeal to the department's designee no later than 60 days after the date of the notice and include (1) a written request for an appeal that specifies the basis upon which the notice for recoupment of overpayment is challenged and any supporting documentation; and (2) a copy of the recoupment notice under 7 AAC 105.260 (c). (g) Except as provided in (l) of this section, a provider that has been denied enrollment by the department or that is disenrolled from Medicaid for a reason other than a reason in 7 AAC 105.400 may appeal the denial or disenrollment under this subsection by submitting (1) a written request that specifies the basis upon which the decision is challenged and includes any supporting documentation; and (2) a copy of the original denial of enrollment or notice of disenrollment. (h) A provider making an appeal under (g) of section must submit the appeal no later than 180 days after the date of the decision to deny enrollment or to disenroll the provider to the department at the address listed in the department's Addresses for Second Level Provider Appeals list, adopted by reference in 7 AAC 160.900 . A decision on appeal under (g) of this section is a final administrative decision, and the department will notify the provider of the provider's right to appeal to the superior court under the Alaska Rules of Appellate Procedure. (i) The department or its designee may not consider a request for a first-level appeal submitted by a provider under (a) - (g) of this section after the date that the appeal must be submitted. (j) Except under (g) and (h) of this section, a provider that is not satisfied with the first-level appeal decision may file a second-level appeal under 7 AAC 105.280 . (k) The provisions of this section do not apply to recoupment actions resulting from audits conducted under 7 AAC 160.100 - 7 AAC 160.130 . (l) A provider may not request a first-level appeal of disenrollment under 7 AAC 105.210 (d), but may apply for a new enrollment under 7 AAC 105.210 . 7 AAC 105.280. Second-level provider appeal. (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 under this section shall (1) include a description of the issue or decision being appealed; (2) specify the basis upon which the decision is challenged; (3) submit all information and materials that the provider requests the department to consider in resolving the appeal, including a copy of the first-level appeal decision; and (4) submit the appeal to the department at the address listed in the department's Addresses for Second Level Provider Appeals list, adopted by reference in 7 AAC 160.900 . (c) The department will not consider an appeal under this section that is submitted after the date that the appeal must be submitted. (d) In an appeal by a provider under this subsection of a decision that was denied because the provider failed to timely file a claim, the department will (1) approve the appeal and pay the maximum amount allowed under 7 AAC 105 - 7 AAC 160 if the department determines that (A) the department committed an error on a claim previously submitted by the provider for the same service to the same recipient on the same day; (B) the claim was timely filed but not processed; or (C) the provider has good cause under (h) of this section for the provider's failure to submit the claim before the billing deadline under 7 AAC 145.005 (c); or (2) deny the provider's appeal if the department determines that the claim was not timely filed. (e) A decision by the department under this section is a final administrative decision, and the department will notify the provider of the provider's right to appeal to the superior court under the Alaska Rules of Appellate Procedure. (f) The provisions of this section do not apply to recoupment actions resulting from audits conducted under 7 AAC 160.100 - 7 AAC 160.130 . (g) Repealed 8/1/2020. (h) The department will find good cause for a provider's failure to submit a claim before the billing deadline under 7 AAC 145.005 (c) if the failure to submit the claim resulted from a condition that was beyond the provider's control or was caused by a condition that the provider could not reasonably be expected to prevent. In this subsection, a condition beyond the provider's control or a condition that the provider could not reasonably be expected to prevent (1) includes (A) a weather condition that causes a mail or travel delay; and (B) a disaster such as a fire, flood, or earthquake; and (2) does not include (A) provider staffing deficiencies; or (B) the recipient's failure to notify the provider of a court, hearing authority, or department decision described in 7 AAC 145.005 (c). 7 AAC 105.290. Reports requested by the department. 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 or explanation until that report or explanation is received. 7 AAC 105.400. Grounds for sanctioning providers. 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 greater compensation than that to which the provider is legally entitled, including charges in excess of a rate established by the department or the provider's usual and customary charges; (3) submitting or causing to be submitted false information for the purpose of meeting prior authorization requirements; (4) failing to disclose or make available to the department records of services provided to Medicaid recipients and records of payments made for them; (5) failing to provide and maintain quality services to Medicaid recipients within accepted medical community standards as adjudged by a body of professional peers equivalently licensed to practice in this state; (6) engaging in a course of conduct or performing an act the department considers deceptive or abusive of the Medicaid program or continuing that conduct following notification that it should cease; (7) breaching the terms of the Medicaid provider agreement or failure to comply with the terms of the provider certification on the Medicaid claims form; (8) overusing the Medicaid program by inducing, or otherwise causing, a recipient to receive services or supplies not required or requested by the recipient; (9) rebating or accepting a fee or portion of a fee or charge for a Medicaid recipient referral; (10) violating any provision of AS 47.07 or any regulation adopted under it; (11) submitting a false or fraudulent application for provider status; (12) violating any law or code of ethics governing the conduct of relevant occupations, professions, or regulated industries; (13) being convicted of a criminal offense relating to performance of a provider agreement with the state or found liable for a negligent act resulting in death or injury to a recipient; (14) failing to meet standards required by state or federal law for participation, including licensure; (15) being excluded from the Medicare program because of fraudulent or abusive practices; (16) following a documented practice of charging recipients for Medicaid services in an amount above the payment made by the department for that Medicaid service; (17) refusing to execute a new provider agreement when requested to do so; (18) failing to correct deficiencies in provider operations after receiving written notice of these deficiencies from the department; (19) being formally reprimanded or censured by an association of the provider's peers for unethical practices; (20) being suspended or terminated from participation in another governmental medical program such as worker's compensation under AS 23.30 , vocational rehabilitation services under AS 23.15.010 - 23.15.210, and Medicare; (21) failing to repay or make arrangements for repaying (A) an identified overpayment or otherwise erroneous Medicaid payment under 7 AAC 105 - 7 AAC 160 ; or (B) an electronic health record incentive payment if the department requires repayment under 7 AAC 165.050 (d)(2); (22) dispensing a lesser quantity of a prescription drug than that prescribed in order to receive multiple dispensing fees for one prescription, unless the prescription drug provider is reducing the prescribed amount in order to dispense no more than a 30-day supply; (23) billing for a prescription drug other than the drug dispensed; (24) billing for an amount in excess of the normal charge to the typical walk-in, cash-paying customer; (25) billing for a prescription refill that was not authorized by the prescriber; (26) falsely submitting a bill specifying that a prescriber required a specific brand name prescription drug rather than a less expensive generic prescription drug that is equivalent; (27) supplying false information on a dispensing fee or drug cost survey initiated by the department in order to establish or revise prescription drug payment rates; (28) failing to submit business records, medical records, or other information required by the department for the administration of the Medicaid program; (29) being convicted of, found not guilty by reason of insanity for, or adjudicated a delinquent for a crime identified as a barrier crime under 7 AAC 10.900 - 7 AAC 10.990 ; (30) failing to comply with the requirements of AS 47.05.300 - 47.05.390 and 7 AAC 10.900 - 7 AAC 10.990 (barrier crimes and conditions; background checks); (31) failing to remove from contact with a recipient an employee or agent who is impaired by being under the influence of alcohol or drugs while providing services to a recipient or whose use of alcohol or drugs interferes with work performance or recipient safety; (32) violating, or knowingly allowing an employee to violate, state or federal laws regulating prescription drugs and controlled substances, including forging prescriptions and unlawfully distributing a prescription drug or controlled substance; (33) failing to report to the department facts known to the provider or a provider's employee regarding the incompetent or illegal practice or conduct of a personal care assistant in connection with personal care services provided under 7 AAC 125.010 - 7 AAC 125.199 ; (34) submitting or causing to be submitted false information under 7 AAC 125.090 ; (35) failing to investigate and impose a sanction upon an employee or agent who knowingly submitted false information under 7 AAC 125.090 ; (36) failing to make available to the department all records of services provided to a recipient and the payments made for those services; (37) performing, or allowing an employee to perform, a service that is beyond that individual's competence or professional training; (38) failing to perform an act that is within an individual's competence and training that is necessary to prevent harm or an increase in the risk of harm to a recipient; (39) violating the disclosure of information provisions of 7 AAC 37.010 - 7 AAC 37.130 ; (40) discriminating, or allowing an employee to discriminate, on the basis of race, religion, color, national origin, ancestry, or sex in the provision of care to a recipient; (41) failing to maintain for each recipient, as required under 7 AAC 105.230 or another provision of 7 AAC 105 - 7 AAC 160 , a contemporaneous and accurate record of the services provided; (42) for a health care professional licensed in a jurisdiction, acting or failing to act in a way that would constitute grounds for denial, suspension, or revocation of that individual's occupational license. 7 AAC 105.410. Sanctions. (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 . (b) In this section, "utilization and quality control peer-review organization" means an organization administered by a grant agency of the federal government and defined under 42 U.S.C. 1320c-1. 7 AAC 105.420. Imposition of sanction. (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. (c) The department will initiate proceedings to suspend or terminate a provider from the Medicaid program under 7 AAC 105.410 , if a provider or an employee of the provider has (1) been convicted of medical assistance fraud under AS 47.05.210 ; (2) been convicted of a crime the department considers a risk to the health or safety of a recipient, including a barrier crime under 7 AAC 10.905 ; (3) been previously suspended under 7 AAC 105.410 due to program abuse or abuse of a recipient; (4) violated 7 AAC 105.430 (c); or (5) terminated from the Medicare program for fraud or abuse of the Medicare program. 7 AAC 105.430. Scope of sanction. (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. (b) A Medicaid provider may not submit to the department a claim for payment for a service provided to a recipient if that service was provided by an employee or agent of the provider who has been suspended or terminated from participation in the Medicaid program, except for those services provided before the suspension or termination. Services provided before the suspension or termination are subject to any sanction that may apply to that provider under 7 AAC 105.410 . (c) If a provider of services violates (b) of this section, the department may suspend or terminate the provider from participation in the Medicaid program. 7 AAC 105.440. Notice of sanction. (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 . (b) The proposed sanction is effective 30 days after the date on the notice if the provider does not request an appeal or submit the information required under 7 AAC 105.460 30 days or less after the date on the notice or 30 days after the date of the final administrative appeal decision upholding the proposed sanction. A proposed immediate suspension issued under 7 AAC 160.140 of a provider's participation in the Medicaid program is effective 10 days after the date on the notice. (c) In addition to the notice under (a) of this section, the department will notify a provider's known professional societies, the Department of Commerce, Community, and Economic Development, and any other federal or state agency that the department is aware has an interest. In the notification, the department will include the findings made by the department, the sanction imposed, and the date the sanction will begin. (d) If a provider's participation in the Medicaid program has been suspended or terminated, the department will send written notice of that sanction to each recipient for whom the provider has submitted a claim for a service provided in the 12 months preceding the date of the notice of sanction. The department will send the written notice to the last mailing address of the recipient known to the department. The department will also publish notice of the sanction in a newspaper of general circulation or use another method of posting or publication. 7 AAC 105.450. Provider education. (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. (c) In addition to the requirements of (a) and (b) of this section, the department may require a provider or employee of a provider to (1) complete a course of study identified by the department; (2) serve a probationary period determined by the department; and (3) reapply for enrollment in the Medicaid program under 7 AAC 105.210 . 7 AAC 105.460. Appeal of sanction. (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, 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. 7 AAC 105.470. Restrictions on payments. (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. (b) The department may continue a restriction imposed under this section until the department issues a notice of informal resolution under (d) of this section or until any related proceedings to impose sanctions against the provider under 7 AAC 105.400 - 7 AAC 105.490 are resolved. (c) Separate from any notice that the department issues under 7 AAC 105.440 , the department will send written notice to a provider before it restricts payment under this section. In the notice, the department will (1) identify the restriction and state that it has been imposed on the payment of claims submitted by the provider; (2) state that the restriction will continue until the department issues a written notice of informal resolution under (d) of this section or until any related proceedings to impose sanctions against the provider under 7 AAC 105.400 - 7 AAC 105.490 are resolved; (3) specify, when appropriate, each type of medical assistance claim to which the restriction applies; (4) specify, when appropriate, general allegations that justify the imposition of the restriction; (5) state that the provider's failure to comply with the restriction imposed under this section may result in the imposition of additional sanctions under 7 AAC 105.410 ; and (6) inform the provider of the right to submit written information and materials for consideration by the department in resolving the matter. (d) The department will remove the restriction and issue a notice of informal resolution if it determines that a provider did not commit the violations alleged or that the violations do not warrant the imposition of sanctions. If the department finds that the provider committed violations, the department will (1) include in the notice of informal resolution a description of each violation, specifying the statute or regulation found to have been violated; and (2) refer the provider to written materials designed to help the provider avoid similar violations in the future. 7 AAC 105.480. Withholding of payments. (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. (c) The withholding of payments to a provider under this section does not preclude the department from imposing other sanctions against the provider under 7 AAC 105.400 - 7 AAC 105.470 . (d) The department will cease withholding payments under this section after the department, or a prosecuting authority, determines that there is insufficient evidence to support allegations of fraud against the provider or after legal proceedings against the provider related to the allegations are completed in the provider's favor on all charges or claims. 7 AAC 105.490. Definitions. 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. 7 AAC 105.600. Restriction of recipient's choice of providers. (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 ; (2) a qualified health care professional employed by or designated by the department determines that a recipient's use of Medicaid services was at a frequency or amount that is not medically necessary based on an evaluation of the recipient's medical or billing history, and with consideration of one or more of the following: (A) data from the prescription drug monitoring program (PDMP) controlled substance prescription database established under AS 17.30.200 ; (B) application of clinical judgment using available information within the scope of practice of the qualified health care professional; (C) the recipient's age, diagnosis, complications, chronic illnesses, use of different medical providers and hospitals, and medical care received; (D) a referral made to the department indicating that the recipient has used a medical item or service at a frequency or amount that is not appropriate; and (E) other tracking tools or information available to the department. (c) Following identification of one or more instances identified in (b) of this section, the department will (1) monitor the recipient's use of Medicaid services for 90 days; or (2) notify the recipient, in writing, (A) that the department will restrict the recipient's choice of provider as provided in (d) of this section; and (B) of the recipient's fair hearing rights under 7 AAC 49 . (d) The department will assign a restricted recipient one primary care provider and one pharmacy within reasonable proximity to the recipient's home, and may assign one dental provider and one behavioral health provider, also within reasonable proximity. The department will include the word "RESTRICTED" and will identify the designated providers on the recipient's Medicaid identification card. (e) A restricted recipient may obtain services and items from only the designated providers identified under (d) of this section, except that (1) the recipient may receive medical services from a non-designated enrolled provider if the designated provider refers the recipient to the non-designated enrolled provider; (2) the recipient may receive emergency services from any enrolled provider. (f) The department may restrict provider choice for a reasonable period of time, not to exceed 24 months of eligibility upon initial placement, and 36 months for each subsequent placement. The department will review the restriction before the end of each placement. The department will notify the recipient, in writing before each subsequent placement, (1) of the department's decision to continue to restrict the recipient's choice of provider under (d) of this section; and (2) of the recipient's fair hearing rights under 7 AAC 49 . (g) The designation of a provider under (d) of this section may be changed only if the (1) provider requests the change; (2) provider disenrolls from the Medicaid program; (3) recipient moves to a new geographic area; or (4) department finds that the recipient does not have reasonable access to Medicaid services of adequate quality. (h) Except as provided in (e) of this section, the department will pay for a service covered under 7 AAC 105 - 7 AAC 160 that is provided to a recipient who is restricted under this section only if the service is performed by a provider designated on the recipient's Medicaid identification card. (i) In this section, (1) "emergency service" means (A) inpatient hospital care provided to a recipient admitted into the hospital from the emergency room of that hospital; (B) outpatient hospital services and physician services provided to a recipient in response to the sudden and unexpected onset of an illness or accidental injury that requires immediate medical attention to safeguard the recipient's life; in this subparagraph, "immediate medical attention" means medical care that the department determines cannot be delayed for 24 hours or more after the onset of the illness or occurrence of the accidental injury; (2) "non-emergent condition" means a condition that does not require an emergency service; (3) "qualified health care professional" means a health care provider who is licensed under AS 08 and whose area of licensure relates to the service or item identified under (b) of this section. 7 AAC 105.610. Recipient cost-sharing. (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). (b) The following services are not subject to recipient cost-sharing requirements under this section: (1) a service provided to a recipient under 18 years of age at the time of delivery of the service; (2) a service provided to a recipient in a long-term care facility; (3) a service provided to a pregnant woman, including a service provided to a woman during the postpartum period under 7 AAC 100.304 ; (4) a family planning service or supply; (5) an emergency service; (6) a hospice care service; (7) a service provided to an American Indian or an Alaska Native by a tribal health program; (8) a service provided to an individual who is eligible for both Medicaid and Medicare, if Medicare is the primary payer for that service; (9) adult preventive and screening services under 7 AAC 110.800 . (c) A provider shall collect the amount of cost-sharing from the recipient and otherwise comply with AS 47.07.042 (a) concerning cost-sharing. (d) The department will reduce payment to the provider by the amount of cost-sharing required under this section for the service provided to that recipient. (e) In this section, "emergency service" means (1) inpatient hospital care provided to a recipient admitted into the hospital from the emergency room of that hospital; and (2) outpatient hospital services and physician services provided to a recipient in response to the sudden and unexpected onset of an illness or accidental injury that requires immediate medical attention to safeguard the recipient's life; in this paragraph "immediate medical attention" means medical care that the department determines cannot be delayed for 24 hours or more after the onset of the illness or occurrence of the accidental injury. Chapter 110 Medicaid Coverage; Professional Services Article 1 Advanced Nurse Practitioner Services 7 AAC 110.100. Advanced practice registered nurse enrollment requirements. (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 as an advanced practice registered nurse in accordance with 7 AAC 105.210 ; (2) has an active license to practice as an advanced practice registered nurse 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 nurses 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 . (b) In addition to meeting the requirements of (a) of this section, to be eligible for payment for laboratory services performed in the advanced practice registered nurse's own laboratory, an advanced practice registered nurse must have 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. A copy of the CLIA certificate of waiver or registration certificate must be submitted with the application for enrollment under 7 AAC 105.210 . (c) In addition to meeting the requirements of (a) of this section, to be eligible for payment for dispensing legend drugs, an advanced practice registered nurse must also be enrolled as a dispensing provider under 7 AAC 120.100 . (d) The department will not pay an advanced practice registered nurse enrolled under 7 AAC 105.210 and this section for services the advanced practice registered nurse provided as a salaried employee of a hospital or services for which the advanced practice registered nurse, through an agreement with a hospital, received compensation in cash or in-kind from the hospital. 7 AAC 110.105. Advanced practice registered nurse services. (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's 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 ; (2) early and periodic screening, diagnosis, and treatment services; and (3) if applicable, dispensing of legend drugs in accordance with 7 AAC 110.100 and 7 AAC 120.100 . (b) The department will pay an advanced practice registered nurse certified as a nurse midwife for services for a normal vaginal delivery performed at a free-standing birth center licensed under AS 47.32 . Article 2 Chiropractic Services 7 AAC 110.120. Chiropractic coverage and limitations. (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 . (b) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing chiropractic services in a group practice, the group must (1) be enrolled in accordance with 7 AAC 105.210 ; and (2) be comprised of one or more individuals who meet the requirements of (a) of this section. (c) The department will only pay for chiropractic services identified in the CPT Fee Schedule for Chiropractic Services table adopted by reference in 7 AAC 160.900 . Subject to the limitations in (d) of this section, the department will pay for manual manipulation to correct a subluxation of the spine, and x-rays necessary for diagnosis, if the subluxation of the spine resulted in a neuromusculoskeletal condition for which manual manipulation is the appropriate treatment. If there is no x-ray to support that a subluxation exists, the recipient's record must contain complete documentation of the examination results justifying manual manipulation for subluxation of the spine. (d) Except as provided in 7 AAC 110.200 (3), the department will not pay for the following chiropractic services: (1) chiropractic services for an individual 21 years of age or older, unless the individual is a Medicare recipient; (2) more than 12 visits to a chiropractor by a recipient in a calendar year; (3) x-rays, except for a diagnostic x-ray of the specific area of the spine requiring treatment; (4) more than one x-ray billing code during a calendar year for a recipient; (5) chiropractic services for a child under six years of age, unless the department has given prior authorization for the service and the service is supported by a referral from a physician, advanced nurse practitioner, or physician assistant; (6) a chiropractic service for which the department has not established a payment rate under 7 AAC 145.110 . (e) A chiropractor must maintain in the chiropractor's place of business a recipient medical record, either written or electronic, containing complete documentation of the examination results justifying manual manipulation for subluxation of the spine when there is no supporting x-ray. (f) In this section, "subluxation" has the meaning given "subluxation complex" in AS 08.20.900 . Article 3 Dental Services 7 AAC 110.140. Dental provider enrollment requirements. (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. (b) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing dental services in a group practice, the group must (1) be enrolled in accordance with 7 AAC 105.210 ; and (2) be comprised of one or more individuals who meet the requirements of (a) of this section. (c) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing dental hygiene services, a dental hygienist must (1) be enrolled as an advanced practice dental hygienist in accordance with 7 AAC 105.210 ; (2) be licensed as a dental hygienist under AS 08.32 ; and (3) hold an active dental hygienist advanced practice permit under AS 08.32.125 . (d) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing dental hygiene services in a group practice, the group must (1) be enrolled in accordance with 7 AAC 105.210 ; and (2) consist of one or more individuals who meet the requirements of (c) of this section. 7 AAC 110.145. Dental services for adults. (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 radio graph 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; (2) a dental service that exceeds a limit established in (b) and (c) of this section if the department determines, based on medical justification submitted with a prior authorization request, that a delay in the provision of the service will endanger the life of the recipient. (b) Subject to appropriation under AS 47.07.067 and except as specifically excluded under (g) of this section, the department will pay up to $1,150 per state fiscal year for the dental services identified in the Fee Schedule: Enhanced Adult Dental Services, adopted by reference in 7 AAC 160.900 and provided to a recipient 21 years of age or older, as follows: (1) periodic or comprehensive oral evaluation not more than one time per fiscal year, panoramic radiographs not more than one time per fiscal year and other dental radio graphs necessary for dental care; (2) preventive care, including (A) prophylaxis, including necessary scaling, polishing, and instructions on oral hygiene and diet, not more than two times per fiscal year; and (B) topical application of fluoride not more than four times per fiscal year, or topical fluoride varnish not more than four times per fiscal year, or a combination of topical application of fluoride and fluoride varnish not more than four times per fiscal year; (3) restorative care for the treatment of decayed or fractured teeth, including amalgams and resins, and crowns if the tooth cannot be restored with amalgams or resin; under this paragraph, (A) a claim submitted for up to two crowns in a single day must be accompanied by medical justification; (B) a provider must obtain prior authorization from the department for three or more crowns in a single day or four or more crowns in a 12-month period; (C) all surfaces restored on a single tooth on the same day are considered connected; therefore, payment is limited to one single or multi-surface restoration code per tooth per day; (D) final restorations are limited to not more than five surfaces per tooth; tooth preparation, temporary restorations, sedative and cement bases, and local anesthesia are considered components of a complete restorative procedure and may not be billed separately; and (E) the department will provide payment for a crown only upon seatment of the permanent crown, and for a partial or denture only upon seatment of the appliance; the department will not provide partial payment for incomplete or in-progress dental services; (4) endodontics, with the following limitations: (A) palliative and sedative treatments may not exceed two times per tooth before a definitive treatment; (B) with respect to root canal therapy, tooth preparation, temporary filling of the root canal, and follow-up care are considered components of a complete root canal and may not be billed separately; (C) a separate claim in addition to a root canal claim may be made for pin retention and restoration, and may not exceed five surfaces per tooth; (5) periodontics, including treatment of pain or acute infection of supporting tissues of the teeth, including gingivitis, periodontitis, and periodontal abscess; (6) oral surgery; under this paragraph, (A) prior authorization from the department is required for extractions; and (B) local anesthesia, materials, and routine postoperative care are considered components of a complete surgical procedure and may not be billed separately; (7) professional consultation, if medically necessary or if requested by the department. (c) Prior authorization from the department is required for prosthodontic services. Except as specifically excluded under (g) of this section, the department will pay up to $1,150 per state fiscal year for prosthodontic services provided to a recipient 21 years of age or older, and up to twice the annual limit if one annual limit is not adequate to cover the cost of the provision of upper and lower dentures at the same time. If the department authorizes use of up to twice the annual limit for dentures, the maximum amount authorized is the remaining amount from the current fiscal year and the entire amount allotted for the succeeding fiscal year limit. In the succeeding fiscal year, the department will not authorize a new or additional annual limit. The department will pay for prosthodontic services identified in Fee Schedule: Prosthodontic Adult Dental Services, adopted by reference in 7 AAC 160.900 , as follows: (1) a complete denture, maxillary; (2) a complete denture, mandibular; (3) a partial denture, maxillary; (4) a partial denture; mandibular; (5) replacement of a complete or partial denture only if the existing denture is unusable and only once per five years, unless the department determines, based on medical justification submitted with the prior authorization request, that a delay will endanger the life of the recipient; (6) replacement of a partial denture with a complete denture not earlier than five years after payment for the partial denture, unless the department determines, based on medical justification submitted with the prior authorization request, that a delay will endanger the life of the recipient; (7) a denture within the same dental arch no more than three times per lifetime, unless the department determines, based on medical justification submitted with the prior authorization request, that a delay will endanger the life of the recipient; (8) adjustments to a complete or partial denture not earlier than six months following the seatment date of the denture and not more than four times per fiscal year; (9) rebase and reline procedures of a complete or partial denture not earlier than six months following the seatment date of the denture and not more than once per three fiscal years. (d) The cost of anesthesia or sedation in accordance with 7 AAC 110.155 and necessary for dental services covered under this section does not reduce the recipient's annual limit described in (b) and (c) of this section. (e) A dental service provided after a recipient's annual limit under (b) and (c) of this section has been exhausted is considered a noncovered service and the department will not provide payment. Notwithstanding 7 AAC 145.015 , a provider may bill a recipient for the difference under (c) of this section if the unused portion of a recipient's annual limit is less than the allowable Medicaid payment rate, or under (b) and (c) of this section if the unused portion of the recipient's combined annual limit is less than the allowable Medicaid payment rate. A provider shall inform a recipient in advance of the recipient's obligation to pay for the difference. The provider shall document in the recipient's records that the recipient was informed of and agreed to pay for any balance above the annual limit for the service provided. (f) The department will assist a provider and recipient to the extent possible in monitoring the recipient's annual limit. However, the department will not assume financial responsibility for dental services provided that exceed the recipient's annual limit. (g) The department will not pay for the following dental services provided to a recipient 21 years of age or older: (1) dental services not identified in the Fee Schedule: Emergent Adult Dental Services, the Fee Schedule: Enhanced Adult Dental Services, and the Fee Schedule: Prosthodontic Adult Dental Services, adopted by reference in 7 AAC 160 . 900; (2) behavior management; (3) indirect pulp capping; (4) endodontic apical surgery and retrograde fillings; (5) immediate, interim, and temporary dentures; (6) dental implant and implant-related dental services; (7) inlays, overlays, and three-fourth crowns; (8) restoration of etched enamel or deep grooves without obvious dentin (9) space maintainers; (10) tobacco counseling; tobacco counseling is considered a component of periodic and comprehensive evaluations and may not be billed separately; (11) denture characterization and personalization, and precision attachments; (12) experimental dental procedures; (13) local anesthesia; local anesthesia is considered a component of covered dental procedures and may not be billed separately; (14) anesthesia or sedation in conjunction with a noncovered service or a service for which service limits have been exhausted; (15) dental sealants; (16) orthodontic services. 7 AAC 110.150. Dental services for recipients under 21 years of age. (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 more than two times per calendar year, limited oral evaluation not more than two times per calendar year, and comprehensive oral evaluation not more than two times per calendar year; panoramic radio graphs not more than one time per calendar year and other dental radiographs as necessary for dental care; (2) preventive care, as follows: (A) prophylaxis, limited to necessary scaling, polishing, and instructions on oral hygiene and diet, not more than two times per calendar year; (B) topical application of fluoride not more than four times per calendar year, or topical fluoride varnish not more than four times per calendar year, or a combination of topical application of fluoride and fluoride varnish not more than four times per calendar year; (C) sealants, limited to one time per tooth per calendar year; and (D) space management therapy restricted to posterior teeth; the department will pay for a primary teeth space maintainer only if a significant risk exists of detrimental drifting occurring before the permanent tooth erupts and for a permanent teeth space maintainer only if prosthodontic treatment is not applicable; (3) restorative care for the treatment of decayed or fractured teeth, including amalgams and resins, and crowns if the tooth cannot be restored with amalgams or resin; under this paragraph, (A) a claim submitted for up to two crowns in a single day must be accompanied by medical justification; (B) a provider must obtain prior authorization from the department for three or more crowns in a single day or four or more crowns in a 12-month period; (C) all surfaces restored on a single tooth on the same day are considered connected; therefore, payment is limited to one single or multi surface restoration code per tooth per day; (D) final restorations are limited to not more than five surfaces per tooth; tooth preparation, temporary restorations, sedative and cement bases, and local anesthesia are considered components of a complete restorative procedure and may not be billed separately; and (E) the department will provide payment for a crown only upon seatment of the permanent crown, and for a partial or denture only upon seatment of the appliance; the department will not provide partial payment for incomplete or in-progress dental services; (4) endodontics, with the following limitations: (A) palliative and sedative treatments may not exceed two times per tooth before a definitive treatment; (B) with respect to root canal therapy, tooth preparation, filling of the root canal, and follow-up are considered components of a complete root canal and may not be billed separately; and (C) a separate claim may be made for pin retention and restoration, and may not exceed five surfaces per tooth; (5) periodontics, including treatment of pain or acute infection of supporting tissues of the teeth, including gingivitis, periodontitis, and periodontal abscess; (6) prosthodontics, including replacement of a complete or partial denture only if the existing denture is unusable and only once per five calendar years; (7) oral surgery; under this paragraph, the following services are covered: (A) extractions; under this subparagraph, (i) a claim submitted for up to two extractions in a single day to alleviate immediate pain or infection must be accompanied by medical justification; (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 to alleviate immediate pain or infection; and (iii) a provider must obtain prior authorization from the department for an extraction that is required for a reason other than to alleviate immediate pain or infection; (B) local anesthesia, materials, and routine postoperative care are considered components of a complete surgical procedure and may not be billed separately; (8) anesthesia and sedation in accordance with 7 AAC 110.155 and necessary for dental services covered under this section; (9) professional consultation, if medically necessary or if requested by the department. (b) Except as provided in 7 AAC 110.200 (3), the department will not pay for the following dental services for recipients under 21 years of age: (1) dental services not identified in the Fee Schedule: Dental Services for Children, adopted by reference in 7 AAC 160.900 ; (2) behavior management in conjunction with any services covered under 7 AAC 110.155 ; (3) indirect pulp capping; (4) endodontic apical surgery and retrograde fillings; (5) immediate, interim, and temporary dentures; (6) dental implant and implant-related dental services; (7) inlays, overlays, and three-fourth crowns; (8) restoration of etched enamel or deep grooves without obvious dentin involvement; (9) space maintainers for anterior teeth; (10) tobacco counseling; tobacco counseling is considered a component of periodic and comprehensive evaluations and may not be billed separately; (11) denture characterization and personalization, and precision attachments; (12) experimental dental procedures; (13) local anesthesia; local anesthesia is considered a component of covered dental procedures and may not be billed separately; (14) anesthesia or sedation in conjunction with a noncovered service. 7 AAC 110.153. Orthodontic services. (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; (2) interceptive orthodontic treatment of the primary or transitional dentition to redirect ectopically erupting teeth, correct isolated dental crossbite, or recover minor space loss where overall space for erupting teeth is adequate; the department will pay for interceptive orthodontic treatment for recipients under 13 years of age; 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; (3) comprehensive orthodontic procedures for treatment of cleft palate for treatment in conjunction with orthognathic surgery for a class III skeletal malocclusion, for treatment based on medical necessity due to functional impairment, or based on a score of 28 or greater on the Handicapping Labiolingual Deviation (HLD) Index Report, adopted by reference in 7 AAC 160.900 , and completed by an orthodontist; the department will pay for interceptive orthodontic treatment for recipients under 13 years of age; when requesting approval for orthodontic treatment the provider must consider the recipient's willingness and ability to attend scheduled appointments and ability to maintain an acceptable level of oral hygiene, which is vital to the success of orthodontic treatment; the prior authorization request must be submitted by the orthodontist and must include (A) a description of the condition including medical information to determine functional impairment; (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) study models, if requested in the process of reviewing the prior authorization; 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; (b) If comprehensive orthodontic treatment commences earlier than 18 months after the most recent limited or interceptive orthodontic treatment, reimbursement for the comprehensive orthodontic treatment will be reduced by the amount reimbursed for limited or interceptive orthodontic treatment. (c) If a recipient's eligibility ends or if the recipient reaches the maximum age for the service before the conclusion of treatment, payment for remaining services is the responsibility of the recipient, or the parent or guardian if the recipient is a minor. (d) The orthodontist may terminate treatment under (a) of this section before completion if the recipient is uncooperative or noncompliant, or if the recipient is no longer eligible for Medicaid. Upon early termination of treatment, the orthodontist shall (1) report early termination of treatment to the department not later than 30 days after termination of treatment; and (2) remove the brackets and, if needed, replace with orthodontic retention. (e) Except for orthodontic treatment of cleft palate, the department will not pay for services under (a) of this section if the recipient has a history of caries during the six months before treatment or if the recipient demonstrates oral hygiene inadequate to successfully complete orthodontic services. (f) Except for orthodontic treatment of cleft palate, the department will not pay for orthodontic treatment under (a)(3) of this section more than one time during the recipient's lifetime 7 AAC 110.155. Dentist-administered anesthesia and sedation. (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 - 7 AAC 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. (c) The cost of the supplies necessary for the administration of anesthesia and sedation, including drugs, nitrous oxide masks, tubing, and syringes, are included in the payment made under (a) and (b) of this section. 7 AAC 110.160. Diagnostic x-ray. Repealed. 7 AAC 110.165. Advanced practice dental hygienist services. (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. (e) The department will not pay an advanced practice dental hygienist for the noncovered services identified in 7 AAC 110.145 (g). (f) An advanced practice dental hygienist may provide services in the following locations to an individual who is unable to access dental hygiene services in a dental office setting because of age, infirmity, or disability: (1) a senior center; (2) a hospital; (3) a long-term care facility; (4) an adult foster home; (5) a residential care facility; (6) an adult congregate living facility; (7) a mental health residential program; (8) a facility for individuals with developmental or other disabilities; (9) fluoride only in a nursery school or day care program; (10) a vocational training facility; (11) a public, private, or charter primary or secondary school; (12) a private home; (13) a dental health professional shortage area (HPSA) designated under 42 U.S.C. 254e. Article 4 Direct-Entry Midwife Services 7 AAC 110.180. Direct-entry midwife coverage and limitations. (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 . (b) Direct-entry midwife services are those services for the management of prenatal, intrapartum, and postpartum care that a direct-entry midwife is certified to provide under 12 AAC 14 . The department will pay for only the direct-entry midwife services identified in the Fee Schedule for Direct-Entry Midwife Services, adopted by reference in 7 AAC 160.900 . (c) The department will not enroll a direct-entry midwife in training or an apprentice. Article 5 EPSDT Services 7 AAC 110.200. Purpose of EPSDT services. The department will pay for early and periodic screening, diagnosis, and treatment (EPSDT) services provided to a recipient under 21 years of age or to a justice-involved youth described in 7 AAC 105.110 (6)(B). If the recipient is a justice-involved youth, EPSDT services covered by Medicaid are limited to screening and diagnostic services under 7 AAC 110.850 . EPSDT services include (1) screening for physical, behavioral, vision, dental, and hearing needs that meet the requirements of 7 AAC 110.205 ; (2) any necessary health care, diagnostic services, treatment, or other services that meet the requirements of 7 AAC 110.210 ; and (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. 7 AAC 110.205. EPSDT screening services. (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. (b) To be covered under 7 AAC 105 - 7 AAC 160 , an EPSDT screening must include (1) a comprehensive medical screening that meets the minimum recommendations of the Bright Futures/American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care, adopted by reference in 7 AAC 160.900 , with additional screenings performed as medically necessary; (2) a dental screening that meets the minimum recommendations of the American Academy of Pediatric Dentistry's Recommendations for Pediatric Oral Health Assessment, Preventive Services, and Anticipatory Guidance/Counseling, and supporting information of the American Academy of Pediatric Dentistry's Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatments for Infants, Children, and Adolescents, adopted by reference in 7 AAC 160.900 ; (3) a vision screening that includes a referral to a vision care services provider at three years of age and annually thereafter; if medically necessary, the department will pay for (A) more frequent examinations by a vision care services provider; or (B) a referral to a vision care services provider before the child is three years of age; (4) a hearing screening and, if medically necessary, referral for diagnosis and treatment of defects in hearing; and (5) lead screenings at 12 months of age and 24 months of age. 7 AAC 110.210. EPSDT covered services. (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 . (c) The department will pay for transportation services identified in (d) of this section if, before the date of travel, the recipient or provider requests prior authorization for travel from the department and if the department determines that (1) the transportation is needed to (A) obtain an EPSDT screening or medically necessary service identified by an EPSDT screening; (B) obtain a prenatal screening and resulting referrals; (C) attend an appointment with a local office responsible within the department for implementing the Special Supplemental Nutrition Program for Women Infants, and Children (WIC) under 42 U.S.C. 1786; (D) obtain necessary medical care for a recipient under 21 years of age, if (i) the medical care involves intercommunity travel; (ii) the medical care is not the result of an EPSDT screening; (iii) the recipient lives in a community not served by a common carrier; and (iv) the recipient is not eligible for transportation services under 7 AAC 120.400 - 7 AAC 120.490 ; or (E) obtain a prescription that is required as a result of an EPSDT or prenatal screening; (2) the recipient is under 21 years of age and eligible for Medicaid under 7 AAC 100 ; (3) other appropriate transportation services are not available; and (4) the medical service requested is not available closer to the recipient's residence. (d) The department will pay for the following transportation services authorized under (c) of this section: (1) a bus token or pass; (2) a taxi, shuttle, or similar form of ground transportation; (3) a mileage payment for use of a private vehicle driven for medical purposes. Article 6 Family Planning Services 7 AAC 110.230. Family planning services. (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. (b) A family planning service provider that operates its own laboratory must have 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. (c) An out-of-state family planning services provider must (1) meet the definition of a family planning services provider in the jurisdiction in which services are provided; (2) be enrolled in the jurisdiction in which it provides services; and (3) enroll as a family planning services provider in this state. (d) The department will pay for the following family planning services provided by a family planning services provider authorized under this section: (1) office visits for counseling services identified by one of the procedure codes in the range of 99201 to 99215 in Current Procedural Terminology (CPT), adopted by reference in 7 AAC 160.900 ; (2) laboratory services performed by a family planning services provider that meets the certificate requirements of (b) of this section; and (3) prescription drugs prescribed in accordance with 7 AAC 120.100 - 7 AAC 120.140 . (e) The department will not pay separately for (1) office supplies and services associated with office visits and procedures identified in (d) of this section; or (2) handling or conveyance of a specimen from one provider to another under procedure codes 99000 and 99001 in Current Procedural Terminology (CPT), adopted by reference in 7 AAC 160.900 . (f) In this section, "family planning services" (1) means services and materials provided with the purpose of postponing, avoiding, or terminating pregnancy; (2) includes the dispensing of birth control drugs and devices for males and females, and the performance of vasectomies, sterilizations, and abortions for the purpose of avoiding or terminating pregnancy. Article 7 Imaging Services 7 AAC 110.240. Imaging services. 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. Article 8 Nurse Anesthetist Services 7 AAC 110.250. Registered nurse anesthetist enrollment and services. (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 . (b) The department will pay a registered nurse anesthetist only for services within the scope of practice of a registered nurse anesthetist under AS 08.68 and 12 AAC 44 . Article 9 Nutrition Services 7 AAC 110.270. Nutrition services provider enrollment requirements. 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 . 7 AAC 110.275. Nutrition services for recipients under 21 years of age. (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. (c) Except as provided in 7 AAC 110.200 (3), the department will pay for the following nutrition services provided to a recipient who meets the requirements of (a) and (b) of this section: (1) one initial assessment, not to exceed one hour, in a calendar year; (2) up to 12 hours of services in a calendar year for counseling and follow-up care after the initial assessment for counseling and follow-up care; (3) more than 12 hours of service in a calendar year if those hours are (A) medically justified and prescribed by a physician, an advanced practice registered nurse, or a physician assistant, who may order those services within the scope of the practitioner's license; and (B) given prior authorization by the department. (d) The department will pay an independently practicing enrolled provider of nutrition services directly. If a provider of nutrition services provides services as a member of the staff of a hospital or other facility that is a Medicaid provider, the department will make payment to the facility. The department will not separately pay for inpatient nutrition services provided to a recipient in a hospital or nursing facility. 7 AAC 110.280. Nutrition services for pregnant women. (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. (b) A pregnant recipient is at high risk nutritionally if the recipient (1) has a chronic or metabolic disease; (2) has a disease or condition that requires a prescribed therapeutic diet; (3) was underweight before conception; (4) has inadequate or excessive weight gain during pregnancy; (5) has a history of substance abuse; (6) has a history of low birth-weight infants; (7) has multiple fetuses; (8) has anemia; (9) has intrauterine growth retardation; or (10) is less than 16 years of age. (c) The department will pay for the following nutrition services provided to a pregnant woman who meets the requirements of (a) and (b) of this section: (1) one initial assessment, not to exceed one hour, in a calendar year; (2) up to 12 hours of services in a calendar year for counseling and follow-up care after the initial assessment; (3) more than 12 hours of service in a calendar year if those hours are (A) medically justified and prescribed by a physician, an advanced practice registered nurse, or a physician assistant who may order those services within the scope of the practitioner's license; and (B) given prior authorization by the department. Article 10 Physician Services 7 AAC 110.400. Physician services provider enrollment requirements. (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 . (b) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing physician services in a group practice, the group must (1) be enrolled in accordance with 7 AAC 105.210 ; and (2) be comprised of one or more individuals who meet the requirements of (a) of this section. (c) In addition to meeting the requirements of (a) of this section, to be eligible for payment for laboratory services performed in the physician's own laboratory, a physician must have 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. A copy of the CLIA certificate of waiver or registration certificate must be submitted with the application for enrollment under 7 AAC 105.210 . (d) In addition to meeting the requirements of (a) of this section, to be eligible for payment for dispensing prescription drugs, a physician must enroll as a dispensing provider under 7 AAC 120.100 . (e) A hospital-based physician must be individually enrolled as a physician under this section. 7 AAC 110.405. Physician services coverage and limitations. (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. (b) The department will pay a physician for vaccine products and administration, in accordance with 7 AAC 110.750 . (c) The department will pay a physician for providing the following services only if those services are provided to a recipient who is under 21 years of age or who is a Medicare recipient: (1) chiropractic manipulation; (2) podiatry services. (d) The department will not pay for the following services provided by a physician: (1) elective surgery that is not medically necessary; (2) infertility services; (3) case management services; (4) plastic or cosmetic services for enhancement purposes; (5) repealed 7/25/2021; (6) services provided in the operating room on behalf of the physician by a licensed practical nurse, a registered nurse, an intern, or a resident in training used in the operating room; (7) medical testimony; (8) travel services; (9) educational services and supplies; (10) interpreter services; (11) experimental or investigative services; (12) swimming therapy; (13) programs to improve overall fitness; (14) impotence treatment or services; (15) vaccine products that are available free to the provider; (16) physical examinations, except if (A) given as a screening under the EPSDT program; (B) the department requests one for the purpose of determining eligibility based upon disability, blindness, or pregnancy; or (C) for recipients 21 years of age and older under 7 AAC 110.800 ; (17) selected special services and report codes. 7 AAC 110.410. Physician services in a nursing facility. (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. (b) In addition to a visit covered under (a) of this section, the department will pay for a physician visit if the physician submits supporting documentation substantiating the medical need for the additional visit. (c) The 30-day limit established in (a)(2) of this section does not apply to a physician service provided in response to a medical emergency. 7 AAC 110.415. Sterilization by a physician. (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. (b) The department may waive the 30-day waiting period required in (a)(4) of this section in cases of premature delivery or emergency abdominal surgery if more than 72 hours has passed since the recipient signed the consent form as required in (a)(3) of this section. (c) The department will not accept a consent in any form if it is obtained from anyone in labor of childbirth, under the influence of alcohol or other drugs, seeking or obtaining an abortion, or determined by a court to be incompetent. (d) The department will not accept a consent form from a recipient who does not speak English, unless the physician has provided an interpreter or can certify that an interpreter was available and used. (e) The department will not pay for sterilization of an individual who is institutionalized in a correctional facility or inpatient psychiatric facility. 7 AAC 110.420. Hysterectomy by a physician. (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. (b) The department will not pay for a hysterectomy performed only for the purpose of rendering a woman permanently incapable of reproducing. 7 AAC 110.425. Obstetrical care by a physician. 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. 7 AAC 110.430. Office medical supplies. 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. 7 AAC 110.435. Physician laboratory services. (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. 7 AAC 110.440. Physician radiology and imaging services. (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. (c) The department will pay for magnetic resonance imaging (MRI), magnetic resonance angiogram (MRA), single-photon emission computerized tomography (SPECT), and positron emission tomography (PET) services that are provided on an outpatient basis and for which the department has given prior authorization. 7 AAC 110.445. Mental health services by a physician. (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). (b) The department will pay a psychiatrist for providing health care services in an inpatient psychiatric hospital, general acute care hospital, nursing facility, intermediate care facility for individuals with an intellectual disability or related condition, or residential psychiatric treatment center. (c) The department will not pay a physician for experimental therapy, nonmedical outpatient therapy, or nonmedical counseling, including any of the following services: (1) repealed 9/1/2023; (2) preparing of reports; (3) narcosynthesis; (4) socialization; (5) recreation therapy; (6) primal therapy; (7) marathon group therapy; (8) megavitamin therapy; (9) pastoral counseling; (10) employment counseling; (11) explanation of an examination to a family member or other responsible person when the explanation is provided outside of a family therapy session; (12) interaction between recipient and provider by means of the Internet, except as provided in 7 AAC 110.620 - 7 AAC 110.639 for telehealth services. (d) The department will not pay a psychiatrist for providing group psychotherapy services to a recipient in an inpatient psychiatric hospital or in a general acute care hospital offering psychiatric services. (e) Mental health services rendered by someone other than a physician, an advanced practice registered nurse, a rural health clinic, or a federally qualified health center must be provided by an individual licensed under AS 08 and within the individual's scope of practice under 7 AAC 135 , or must be provided by a tribal health program. 7 AAC 110.450. Surgical assistant. (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 acting as a surgical assistant apart from the payment made to the surgeon. 7 AAC 110.455. Physician assistant enrollment and services. (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; (2) if the physician assistant is a federal employee described in 7 AAC 105.200 (c), must (A) submit a copy of the collaborative plan with the supervising physician, if a collaborative plan is required by the physician assistant's licensing jurisdiction; and (B) notify the department of any changes to the collaborative plan by submitting a copy of the new plan. (b) For the department to provide payment under 7 AAC 145.200 , a physician assistant who furnishes services directly to a recipient out of state must separately enroll with the department as a rendering provider under 7 AAC 105.210 and must (1) have an active license to practice in the jurisdiction in which the service is provided unless the physician assistant is a federal employee described in 7 AAC 105.200 (c); (2) provide a copy of the collaborative plan with the supervising physician, if a collaborative plan is required by the physician assistant's licensing jurisdiction; (3) provide proof of enrollment in the Medicaid program in the jurisdiction in which the service is provided or documentation from that jurisdiction that physician assistants are not enrolled as Medicaid providers in that jurisdiction; and (4) notify the department of any changes to the collaborative plan by submitting a copy of the new plan. (c) The department will pay for the services of a physician assistant acting as a surgical assistant under 7 AAC 110.450 . Article 11 Podiatry Services 7 AAC 110.500. Podiatry services provider enrollment requirements. (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 . (b) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing podiatry services in a group practice, the group must (1) be enrolled in accordance with 7 AAC 105.210 ; and (2) be comprised of one or more individuals who meet the requirements of (a) of this section. (c) In addition to meeting the requirements of (a) of this section, to be eligible for payment for laboratory services performed in the podiatrist's own laboratory, a podiatrist must have 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. A copy of the CLIA certificate of waiver or registration certificate must be submitted with the application for enrollment under 7 AAC 105.210 . (d) In addition to meeting the requirements of (a) of this section, to be eligible for payment for dispensing prescription drugs, a podiatrist must enroll as a dispensing provider under 7 AAC 120.100 . 7 AAC 110.505. Podiatry services. (a) The department will pay for the podiatry services and supplies identified in the CPT Fee Schedule for Podiatry Services table and HCPC Fee Schedule for Podiatry Services table, adopted by reference in 7 AAC 160.900 , provided to a Medicaid recipient under 21 years of age who has been found to need medical services relating to specific conditions of the ankle or foot, if (1) a physician has prescribed the treatment; and (2) the treatment provided is within the scope of practice of the treating podiatrist who meets the requirements of 7 AAC 110.500 . (b) The department will not pay for podiatry services for individuals 21 years of age or older, unless the individual is a Medicare recipient. Article 12 Private-Duty Nursing Services 7 AAC 110.520. Private-duty nursing agency enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing private-duty nursing services, a provider must (1) be enrolled as a private-duty nursing agency in accordance with 7 AAC 105.210 ; and (2) be enrolled as either a hospice service provider under 7 AAC 140.270 , or a home health service provider under 7 AAC 125.300 , who employs a registered nurse, a licensed practical nurse, or an advanced practice registered nurse. (b) The employee of a private-duty nursing agency who furnishes services directly to a recipient must (1) be separately enrolled as (A) a rendering provider of private-duty nursing services in accordance with 7 AAC 105.200 (b) and 7 AAC 105.210 , if the rendering provider is a licensed practical nurse or a registered nurse; or (B) an advanced practice registered nurse in accordance with 7 AAC 105.200 (a) and 7 AAC 105.210 ; (2) have an active license to practice as a registered nurse, a licensed practical nurse, or an advanced practice registered nurse issued by the jurisdiction in which the nurse provides services; if services are provided in this state the nurse must hold an active license under AS 08.68 ; and (3) if practicing out of state, be enrolled as a provider or rendering provider of private-duty nursing services in the jurisdiction in which services are provided. 7 AAC 110.525. Private-duty nursing services; covered and noncovered services. (a) The department will pay for private-duty nursing services, if they are provided to a recipient who (1) is under 21 years of age; (2) has been recently discharged from a general acute care hospital or long-term care facility, or has a physical health status that would justify admission to a general acute care hospital or long-term care facility; (3) with the provision of private-duty nursing services, will be able to live in a family setting, and for whom those services will prevent admission to, or promote early discharge from, a general acute care hospital or long-term care facility; and (4) requires more individual and continuous care than is available from a visiting nurse or is routinely provided by the nursing staff of a hospital, a skilled nursing facility, or an intermediate care facility; in this paragraph, "continuous care" means a minimum of eight hours provided to an individual in a 24-hour period. (b) The department will pay for private-duty nursing services only if (1) the services are for a life threatening condition, and a private-duty nursing agency employee can safely provide them outside of an institution; (2) the services are provided under a plan of care approved by the recipient's attending physician, who has participated in the development of the plan of care before any private-duty nursing services were provided and has made a commitment to oversee the recipient's care throughout the duration of the plan of care; (3) the services are required less than 24 hours per day; and (4) a competent individual residing with the recipient has agreed to participate in caring for the recipient in accordance with the plan of care developed under (2) of this subsection. (c) If a private-duty nursing agency provides a skilled nursing service, that service must be provided by a private-duty nursing agency employee for whom the service is within the scope of that employee's license to practice, and who provides the service while under the continued direction of the recipient's attending physician. In this subsection, "skilled nursing service" has the meaning given in 7 AAC 125.399 . (d) Private-duty nursing services include (1) assessment; (2) administration of treatment related to technological dependence; and (3) monitoring and maintaining parameters, machinery, and interventions. (e) A private-duty nursing service may not be performed by (1) a personal care assistant; (2) a home health aide; (3) a member of the immediate family; or (4) other members of the recipient's household. (f) Private-duty nursing services do not include housekeeping, laundry, shopping, meal preparation, or transportation. (g) This section does not apply to specialized private-duty nursing services under 7 AAC 130.285 provided to a recipient who is receiving home and community-based waiver services. (h) The department will not pay for a private-duty nursing service (1) if requested to enable the recipient to attend school or other activities outside the home, and if the same service is not needed to enable the recipient to live successfully in the home, hospital, or nursing facility; (2) during the hours a recipient attends a child care facility; (3) for a recipient that is home schooled; (4) in excess of the private-duty nursing services already authorized by the department; (5) that is considered nurse supervision, including chart reviews, case discussions, scheduling of services, and respite care; (6) that is provided for other members of the recipient's household; or (7) for which the department has not given prior authorization under 7 AAC 110.530 . 7 AAC 110.530. Private-duty nursing services; prior authorization. (a) Private-duty nursing services must be authorized by the department before services are provided. The department will authorize private-duty nursing services for periods up to 60 days, starting on the date the first service is to be provided. (b) To be considered by the department, a prior authorization request must originate from a private-duty nursing agency provider who submits the request in writing or electronically on a form provided by the department. The prior authorization request must (1) include the plan of care developed in accordance with 7 AAC 110.525 (b)(2) and signed by the recipient's attending physician; (2) include a nursing assessment; (3) include any supporting documentation, if applicable; (4) identify the day of actual or planned hospital or nursing facility discharge, if applicable; (5) identify any planned surgical interventions; (6) identify the number of days services are needed, not to exceed a 60-day period; and (7) identify the exact number of hours requested per day. (c) To request additional hours within a 60-day period under (a) of this section, the private-duty nursing agency must submit, before the expiration of the current 60-day period, a new request for prior authorization. The new request must include (1) daily nursing notes; (2) an updated plan of care signed by the recipient's attending physician; (3) the attending physician's order for service dated no sooner than seven days before the date of the request under this subsection; (4) recent significant clinical findings from the recipient's attending physician; and (5) recent clinic summaries. (d) The department will approve a request for additional hours under (c) of this section, if (1) the department finds that the individual who has agreed, in accordance with 7 AAC 110.525 (b)(4), to participate in caring for the recipient, (A) needs additional training; (B) has become ill; (C) is temporarily unable to provide the required care for the recipient; or (D) is unable to provide the required care for the recipient because of a family emergency involving the caregiver; (2) an acute episode has occurred that would otherwise require hospitalization, and the attending physician has determined that noninstitutionalized care is still safe for the recipient; or (3) the need for additional hours is medically necessary. (e) The department may increase or decrease the number of hours authorized under (c) of this section at any time based upon evidence from the attending physician that the recipient's condition, needs, or situation has changed. Article 13 Psychologist Services 7 AAC 110.550. Psychologist testing services. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing psychologist testing services, a provider must be an independently practicing psychologist who (1) is enrolled as a psychologist in accordance with 7 AAC 105.210 ; (2) has an active license to practice psychology issued by the jurisdiction in which the psychologist provides services; if services are provided in this state, the psychologist must hold an active license under AS 08.86.130 or 08.86.135; and (3) maintains records in accordance with (e) of this section. (b) Covered psychologist testing services are limited to medically necessary psychological testing to determine the status of the patient's mental, intellectual, and emotional functioning. Testing services must include administration of psychodiagnostic tests, the interpretation of the results of the tests, and a written report. Testing services must be provided directly by the psychologist. Payment is limited to the following services: (1) psychological testing; (2) assessment of aphasia; (3) developmental testing, limited or extended; (4) neurobehavioral status examination, including assessment of thinking, reasoning, and judgment; (5) neuropsychological testing. (c) Psychologist testing services may be provided to a recipient who has received a referral from the recipient's treating physician, a physician assistant, an advanced practice registered nurse, a community mental health clinic, a tribal health program, or an appropriate school official, if the referral documents the purpose for the testing, including the need to determine acuity of need, severity of symptoms, or level of impairment. (d) Psychologist testing services may be provided in the psychologist's office, an outpatient clinic, an outpatient hospital, a general acute care hospital, a tribal health program, an inpatient psychiatric hospital, a residential psychiatric treatment center, or other setting appropriate for patient care. (e) To be paid by the department for services provided under this section, a psychologist must maintain a specific record for all services provided, that (1) identifies the source and reason for the referral; (2) identifies the questions and issues that the testing addressed; (3) identifies the psychological tests and techniques used; and (4) includes the interpretation of all completed and attempted tests with observations, conclusions, and recommendations. 7 AAC 110.555. Psychologist behavioral health services. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 , psychologist behavioral health services must be provided by an individual who meets the requirements in 7 AAC 110.550 (a)(1) and (2). (b) A provider may only bill the department for the following psychologist behavioral health services, provided in accordance with this chapter: (1) a mental health intake assessment; (2) an integrated mental health and substance use intake assessment; (3) individual psychotherapy; (4) group psychotherapy; (5) family psychotherapy; (6) multi-family group psychotherapy; (7) screening and brief intervention services described in 7 AAC 135.240 ; (8) behavioral health screening under 7 AAC 135.100 . (c) A psychologist behavioral health services provider must maintain the provider's records in accordance with 7 AAC 105.230 . (d) If a psychologist covered under this section provides behavioral health services in or for another enrolled provider, the psychologist must request payment for those services in accordance with 7 AAC 135.910 . Article 14 Clinical Social Worker Services 7 AAC 110.565. Clinical social worker services. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing clinical social worker services, a provider must (1) be enrolled as a clinical social worker in accordance with 7 AAC 105.210 ; and (2) have an active license to practice as a clinical social worker issued by the jurisdiction in which the clinical social worker provides services; if services are provided in this state, the clinical social worker must hold an active license under AS 08.95.110 or 08.95.120. (b) Clinical social worker services include only the following behavioral health clinic services without prior authorization: (1) a mental health intake assessment; (2) an integrated mental health and substance use intake assessment; (3) individual psychotherapy; (4) group psychotherapy; (5) family psychotherapy; (6) multi-family group psychotherapy; (7) screening and brief intervention services described in 7 AAC 135.240 ; (8) behavioral health screening under 7 AAC 135.100 . (c) A clinical social worker services provider must maintain the provider's records in accordance with 7 AAC 105.230 . (d) If a clinical social worker covered under this section provides behavioral health services in or for another enrolled provider, the clinical social worker must request payment for those services in accordance with 7 AAC 135.910 . Article 15 Marital and Family Therapy Services 7 AAC 110.575. Marital and family therapy services. (a) To be eligible to provide marital and family therapy services for payment under 7 AAC 105 - 7 AAC 160 , a provider must (1) be enrolled as a marital and family therapist under 7 AAC 105.210 ; and (2) have an active license to practice as a marital and family therapist issued by the jurisdiction in which the marital and family therapist provides services; if services are provided in this state, the marital and family therapist must hold an active license under AS 08.63.100 . (b) The department will only pay for covered marital and family therapy services. Covered marital and family therapy services are limited to the following behavioral health clinic services without prior authorization: (1) a mental health intake assessment; (2) an integrated mental health and substance use intake assessment; (3) individual psychotherapy; (4) group psychotherapy; (5) family psychotherapy; (6) multi-family group psychotherapy; (7) screening and brief intervention services described in 7 AAC 135.240 ; (8) behavioral health screening under 7 AAC 135.100 . (c) A marital and family therapy services provider must maintain records in accordance with 7 AAC 105.230 . (d) If a marital and family therapist covered under this section provides marital and family therapy services for another enrolled provider, the marital and family therapist must request payment for those services in accordance with 7 AAC 135.910 (a). Article 16 Professional Counseling Services 7 AAC 110.585. Professional counseling services. (a) To be eligible to provide professional counseling services for payment under 7 AAC 105 - 7 AAC 160 , a provider must (1) be enrolled as a licensed professional counselor under 7 AAC 105.210 ; and (2) have an active license to practice as a professional counselor issued by the jurisdiction in which the professional counselor provides services; if services are provided in this state, the professional counselor must hold an active license under AS 08.29 . (b) The department will only pay for covered professional counseling services. Covered professional counseling services are limited to the following behavioral health clinic services without prior authorization: (1) a mental health intake assessment; (2) an integrated mental health and substance use intake assessment; (3) individual psychotherapy; (4) group psychotherapy; (5) family psychotherapy; (6) multi-family group psychotherapy; (7) screening and brief intervention services described in 7 AAC 135.240 ; (8) behavioral health screening under 7 AAC 135.100 . (c) A professional counseling services provider must maintain records in accordance with 7 AAC 105.230 . (d) If a licensed professional counselor covered under this section provides professional counseling services for another enrolled provider, the licensed professional counselor must request payment for those services in accordance with 7 AAC 135.910 (a). Article 17 Targeted Case Management 7 AAC 110.600. Targeted case management for children with disabilities. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing targeted case management services, a provider must (1) be enrolled as a provider of those services in accordance with 7 AAC 105.210 ; (2) be a grantee of the department under AS 47.20 and 7 AAC 23 ; and (3) provide documentation of at least one year of experience in (A) effective work with children and families, involving a demonstrated capacity to provide all core elements of case management including assessment, development of the individualized family service plan, implementation, coordination, and reassessment; (B) coordinating and linking community medical, social, educational, and other resources as required by the target population identified in (b) of this section; (C) working with the target population identified in (b) of this section; and (D) financial management that provides documentation of service and costs. (b) The department will pay a provider for targeted case management provided to a child who is eligible for infant learning program services under 7 AAC 23.080 if the child is at risk for or currently experiencing a developmental delay or disability. (c) The department will pay a provider for targeted case management provided to a child described in (b) of this section to assist and enable the child to gain access to needed medical, social, educational, developmental, and related services. Targeted case management may be delivered in person, electronically, or by telephone. (d) Targeted case management services include an intake and needs assessment that includes the ongoing systematic collection of data to determine current status and identify needs in physical, environmental, psychosocial, developmental, educational, social, behavioral, emotional, and mobility areas. A case manager who meets the requirements of (h) of this section shall collect data from a family interview, existing available records, and the needs assessment. (e) The case manager shall develop an individualized family service plan (IFSP) under AS 47.20.100 in conjunction with the family and other team members involved to identify goals, outcomes, objectives, and issues identified during the intake and needs assessment. Developing the individualized family service plan includes (1) determining activities to be completed by the case manager in support of the child and family, including obtaining appropriate health, mental health, social, educational, developmental, and transportation services to meet the child's needs; (2) coordination and monitoring of services provided; (3) establishing and maintaining, with individuals and agencies, a referral process that avoids duplication of services to the child and family; (4) planning that identifies needs, goals, objectives, and resources in a coordinated, integrated fashion with the family and other involved agencies; (5) implementing the individualized family service plan and monitoring its status; and (6) supporting the family to reach the goals of the individualized family service plan. (f) The case manager, in consultation with the family and other team members involved, shall monitor whether the services continue to meet the child's and family's needs. The case manager shall make adjustments and new or additional referrals to adequately meet the child's and family's needs. (g) The targeted case management services must (1) assist families of eligible children in gaining access to infant learning program services under AS 47.20 and 7 AAC 23 and other medical or social services identified in the individualized family service plan; (2) coordinate and monitor the delivery of infant learning program services under AS 47.20 and 7 AAC 23 and other medical or social services that the child needs or is being provided; (3) inform families of availability of advocacy services; and (4) provide maintenance of a record of case management activities in each child's file. (h) A case manager must (1) be an employee or contractor of the infant learning program grantee; and (2) have demonstrated knowledge and understanding about (A) the infant learning program under AS 47.20 and 7 AAC 23 ; (B) the nature and scope of Medicaid and other services available under the infant learning program; (C) the system of payment for services; (D) children eligible for the infant learning program under AS 47.20 and 7 AAC 23 ; (E) typical and atypical child development, family systems theory, developmentally appropriate intervention strategies, and emotional and behavioral delays and disorders; (F) interviewing skills to gather data, for development of service plans, and for individual and group communications; and (G) state and federal laws relating to child welfare and community resources. (i) An eligible family may choose among the enrolled providers of targeted case management who provide services to the geographic area in which the family resides. 7 AAC 110.605. Targeted case management for justice-involved youth. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing a targeted case management service to a justice-involved youth, (1) a provider must be enrolled in accordance with 7 AAC 105.210 , and must provide documentation of at least one year of experience in (A) effective work with individuals reentering the community from a public institution; the work must demonstrate the provider's ability to provide the core elements of case management, including (i) comprehensive assessment and periodic reassessment of an individual's needs; and (ii) developing, implementing, coordinating, and administering reassessment of an individualized service plan; (B) coordinating and linking community medical, social, and other resources as required by the target population identified in (b) of this section; and (C) working with the target population identified in (b) of this section; or (2) the provider must be an employee of the state who provides case management within the Department of Corrections or Department of Family and Community Services. (b) The department will pay a provider for a targeted case management service provided to a justice-involved youth under 7 AAC 105.110 (6)(B) for (1) up to 30 hours during the time period (A) beginning 30 days before the recipient's release from incarceration as an inmate of a public institution; and (B) ending 30 days after the recipient's release from incarceration as an inmate of a public institution; and (2) additional hours if the department gives prior authorization based on medical justification submitted by the provider. (c) A targeted case management service provided to a justice-involved youth may be delivered by means of a telehealth modality under 7 AAC 110.620 - 7 AAC 110.639 . (d) A targeted case management service provided to a justice-involved youth may include (1) comprehensive assessment and periodic reassessment of individual needs, to determine the need for a medical, educational, social, or other service; (2) development and periodic revision of an individualized service plan based on the information collected through the assessment; (3) referral and related activities, including (A) scheduling appointments to help the eligible individual obtain needed services; and (B) activities to help link the eligible individual with medical, social, and educational providers or other programs and services that may provide needed services to address identified needs and achieve goals specified in the service plan; or (4) monitoring and follow-up activities, including activities and contacts that are necessary to ensure that the service plan is effectively implemented and adequately addresses the needs of the eligible individual during the covered period of the targeted case management service. Article 18 Telehealth 7 AAC 110.620. Scope of telehealth. Subject to the requirements of 7 AAC 110.620 - 7 AAC 110.639 , the department will pay for a service delivered by means of a telehealth modality if the service (1) would be covered under 7 AAC 105 - 7 AAC 160 if delivered in person; and (2) is delivered in compliance with (A) the same requirements of 7 AAC 105 - 7 AAC 160 , including prior authorization requirements and service limitations, as if the service was delivered in person; and (B) the requirements of AS 08.01 , AS 08.68 , AS 47.07 , and 7 AAC 105 - 7 AAC 160 , including the telehealth requirements and limitations of 7 AAC 110.620 - 7 AAC 110.639 , as applicable to the service, the provider, and the mode of delivery. 7 AAC 110.625. Telehealth modalities. (a) Subject to the requirements of 7 AAC 110.620 - 7 AAC 110.639 , the department will pay for a service delivered by means of one of the following telehealth modalities if the modality and use of the modality meet the requirements of P.L. 104 - 191 (Health Insurance Portability and Accountability Act of 1996 (HIPAA)): (1) synchronous: live or interactive, through a real-time, interactive (A) two-way audio-video technology that includes, at a minimum, an operational camera, microphone, speaker or headphones, and capability to view video feed; (B) two-way audio-only technology that allows for oral communication between the provider and the recipient; (2) asynchronous: a store-and-forward, through the transfer from one location to another, of recorded digital images, data, video, or sounds to allow a consulting provider to obtain information, analyze it, and report back to the rendering provider. (b) For patient-initiated online digital service, whether synchronous or asynchronous, the following are not reimbursable: (1) nonevaluative or nonmanagement services including appointment scheduling and electronic communication of test results; (2) provider-initiated online digital service; (3) patient-initiated online digital service within the postoperative period of a completed procedure or within seven days of an in-person visit and related to the illness, injury, or other reason for that visit. 7 AAC 110.630. Telehealth provider requirements and conditions for payment. Subject to the requirements of 7 AAC 110.620 - 7 AAC 110.639 , to be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing a service by means of a telehealth modality, a provider must meet the following requirements: (1) the provider must have an active license under AS 08 or AS 47 , an active certification in the state, or an active license under the applicable laws of the jurisdiction in which the provider is located; (2) the provider must be enrolled under 7 AAC 105.210 ; (3) the provider, if licensed under AS 08 and required under 12 AAC 02.600 , must be registered under 12 AAC 02.600 (telemedicine business registry); (4) the service must be delivered within the rendering provider's, and if applicable, consulting provider's scope of licensure or certification; (5) a claim submitted to the department must include applicable telehealth modifiers and place-of-service coding; (6) if the rendering provider or consulting provider determines, during a telehealth encounter, that a service extends beyond the scope of that provider's license or certification, the provider must discontinue the encounter and refer the recipient to an appropriate provider; the rendering provider or consulting provider may bill only for the portion of the encounter that was within that provider's scope of license or certification and only if the rendered portion of the encounter met all criteria of a separately billable service; (7) except as otherwise provided in 7 AAC 105 - 7 AAC 160 , a recipient must be present during and participate in a telehealth encounter; (8) the provider must comply with all record keeping requirements set out under 7 AAC 105.230 for all telehealth services rendered; (9) the rendering provider and consulting provider, when delivering a service by means of a synchronous telehealth modality, must annotate the patient's clinical record with the method of delivery, the recipient's location during the delivery of the service, and confirmation that the recipient has consented to a telehealth method of delivery. 7 AAC 110.635. Telehealth exclusions. The department will not pay (1) for the use, or any costs associated with the use, of technological equipment and systems associated with the delivery of a service by means of a telehealth modality; (2) a provider for communication with that provider's supervising provider or communication with a provider who is acting in a supervisory capacity; (3) a supervising provider or a provider who is acting in a supervisory capacity for communication with a supervisee or for review of a supervisee's work; (4) a provider participating in a telehealth encounter whose sole purpose is to facilitate the telehealth encounter between the recipient and a rendering provider or a consulting provider; (5) for a failed or unsuccessful telehealth connection or transmission; (6) for the following services when provided by means of a telehealth modality: (A) chiropractic services; (B) dental services; (C) private-duty nursing services; (D) pharmacy dispensing services; (E) durable medical equipment and related services; (F) prosthetic and orthotic devices and related services; (G) transportation services; (H) accommodation services; (I) personal care services; (J) home health services; (K) Community First Choice services; (L) home and community-based waiver services, except for (i) care coordination services under 7 AAC 130.240 ; (ii) day habilitation services under 7 AAC 130.260 ; (iii) employment services under 7 AAC 130.270 ; or (iv) intensive active treatment services under 7 AAC 130.275 ; (M) Long term services and supports targeted case management services, except for case management services provided under 7 AAC 128.010 (b)(2). 7 AAC 110.639. Telehealth definitions. In 7 AAC 110.620 - 7 AAC 110.639 , (1) "consulting provider" means a provider who evaluates a recipient's healthcare information by means of a telehealth modality based on a referral or request from another provider; (2) "patient-initiated online digital service" means evaluation, assessment, and management services of an established patient through a secure platform such as an electronic health record portal, secure electronic mail, or digital application when the patient is the originator of the interaction with the provider; (3) "provider" means a professional, facility, or other type of provider and includes a rendering provider, a referring provider, and a consulting provider; (4) "rendering provider" means a provider who evaluates, diagnoses, and treats a recipient; (5) "referring provider" means a rendering provider who refers a recipient to another rendering provider to diagnose or treat the recipient when the recipient requires services or a specialty beyond the scope of the license or certification of the rendering provider making the referral; (6) "telehealth" means the practice of health care delivery, evaluation, diagnosis, consultation, or treatment using the transfer of medical data, audio, visual, or data communications at two or more locations between a provider and recipient who are physically separated from each other. Article 19 Vision Care Services 7 AAC 110.700. Vision care provider enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing vision care services, a provider must (1) be enrolled as a vision care provider in accordance with 7 AAC 105.210 ; (2) have an active license to practice as an ophthalmologist, an optometrist, or an optician issued by the jurisdiction in which the individual provides services; if services are provided in this state the individual must be actively licensed as (A) a physician under AS 08.64 , who is certified as an ophthalmologist by the American Academy of Ophthalmology; (B) an optometrist under AS 08.72 ; or (C) a dispensing optician under AS 08.71 . (b) To be eligible for payment under 7 AAC 105 - AAC 160 for providing vision care services in a group practice, the group must (1) be enrolled in accordance with 7 AAC 105.210 ; and (2) be comprised of one or more individuals who meet the requirements of (a) of this section. (c) The department may designate one or more enrolled vision care providers for the purchase of frames or lenses through a contract for services under AS 36.30 . 7 AAC 110.705. Vision care services. (a) The department will pay for only the vision services and products identified in the Fee Schedule for Vision Services, adopted by reference in 7 AAC 160.900 , subject to the provisions of this section. (b) The department will pay for the following services in each calendar year for a recipient under 21 years of age: (1) one vision examination if the vision examination meets the requirements of 7 AAC 110.710 ; (2) any vision examination, in addition to the examination in (1) of this subsection, if the department gives prior authorization based upon medical justification submitted by the provider; (3) one complete pair of eyeglasses, or a one-year supply of contact lenses, that meets the requirements of (d) of this section; (4) one additional complete pair of eyeglasses, or additional supply of contact lenses prorated for the remainder of the year, that meets the requirements of (d) of this section, if the (A) first pair of eyeglasses or supply of contact lenses is lost or broken; or (B) prescription changes; (5) any subsequent complete pair of eyeglasses, or subsequent supply of contact lenses prorated for the remainder of the year, that meets the requirements of (d) of this section, if the department gives prior authorization based upon medical justification submitted by the provider; (6) one fitting for each pair of glasses covered under this subsection. (c) The department will pay for the following services for a recipient 21 years of age or older: (1) in each calendar year period (A) one vision examination, if the vision examination meets the requirements of 7 AAC 110.710 ; (B) any vision examination, in addition to the examination in (A) of this paragraph, if the vision examination meets the requirements of 7 AAC 110.710 and if the department gives prior authorization based on medical justification submitted by the provider; (2) in each two-year calendar year period (A) one complete pair of eyeglasses, or two one-year supplies of contact lenses that meet the requirements of (d) of this section; (B) one additional complete pair of glasses, or additional supply of contact lenses prorated for the remainder of the two-year period, that meets the requirements of (d) of this section, if the department gives prior authorization based on medical justification submitted by the provider; (C) one fitting for each pair of glasses covered under this paragraph. (d) The department will pay for contact lenses and contact lens fittings that meet the requirements of this section if (1) the claim is accompanied by written medical justification; and (2) contacts are medically necessary as a result of (A) cataract surgery; (B) aphakia; (C) keratoconus; (D) corneal degeneration; (E) rejection of an implant; or (F) ocular surface disease or abrasion requiring temporary bandaging contact lens. (e) In addition to authorization requirements identified in this section, the following vision products and services require prior authorization by the department, based upon medical justification submitted by the provider: (1) ultraviolet coating; (2) prism lenses; (3) specialty lenses; (4) specialty frames; (5) tinted lenses. 7 AAC 110.710. Complete vision examination. (a) For a clinically indicated complete vision examination with a check of refractive state, the ophthalmologist or optometrist performing the examination shall (1) record a complete case history, including ocular, physical, occupational, and medical data and other pertinent information; (2) determine the best corrected visual acuity; (3) perform an external examination of the eyes and adnexa; (4) perform an internal ophthalmoscopic examination; (5) determine ocular motility and neurological integrity; (6) perform a near-point subjective examination, dynamic retinoscopy, and subjective refraction; and (7) if clinically indicated, perform test accommodation, convergence, and binocular coordination at far and near distances with a phorometer. (b) In addition to the requirements of (a) of this section, if contact lenses are prescribed and covered in accordance with 7 AAC 110.715 , a complete vision examination must include a (1) slit-lamp evaluation; (2) fluorescein examination; and (3) diagnostic evaluation if soft lenses are prescribed. 7 AAC 110.715. Noncovered vision care services. The department will not pay for (1) aspherical lenses; (2) progressive or no-line multi-focal lenses; (3) vision therapy services for a recipient 21 years of age or older; (4) polarized lenses; (5) anti-reflective or mirror coating; (6) lenses for placement into frames that are not covered under 7 AAC 110.705 ; (7) the placement of any lenses into frames that are not covered under 7 AAC 110.705 ; (8) fitting of a vision product that is not covered under 7 AAC 110.705 ; or (9) repair of a vision product that is not covered under 7 AAC 110 . 705. Article 20 Vaccine Services 7 AAC 110.750. Vaccine services. (a) To be a covered vaccine product, a vaccine product must be one (1) for which the United States Food and Drug Administration (FDA) requires a national drug code (NDC) number; and (2) that is listed electronically with the FDA. (b) The department will pay for the following vaccine services provided by a provider who is acting within the scope of the individual's license or certificate to practice: (1) a vaccine product for a recipient under 21 years of age, unless the product is available at no cost to the provider; (2) the administration of a vaccine product to a recipient under 21 years of age; (3) for a recipient 21 years of age or older, the following vaccine products, unless they are available at no cost to the provider, and the administration of those vaccine products, regardless of whether they are available at no cost to the provider: (A) Hepatitis A; (B) Hepatitis B; (C) Herpes Zoster (Shingles); (D) Human Papillomavirus; (E) Measles, Mumps, and Rubella (MMR); (F) Meningococcal; (G) Pneumococcal; (H) seasonal Influenza; (I) Tetanus Diphtheria (Td); (J) Tetanus, Diphtheria, and Acellular Pertussis (Tdap); (K) Varicella (Chickenpox); (L) Haemophilus Influenzae Type B; (M) post-exposure rabies vaccine or immune globulin; (N) pandemic influenza; (O) a vaccine product, and administration of a vaccine product, related to (i) a state public health disaster emergency declared by the governor under AS 26.23.020 ; or (ii) a federally declared public health emergency. (c) The department will not pay for the following vaccine services: (1) vaccine products and administration for the sole purpose of international travel; and (2) pre-exposure rabies vaccine product and administration. Article 21 Preventive Services for Adults 7 AAC 110.800. Preventive services for adults. (a) The department will pay for the following preventive and screening services for a recipient 21 of age or older: (1) an evidence-based item or service with an A or B rating by the United States Preventive Services Task Force (USPSTF) A & B Recommendations for Adults, adopted by reference in 7 AAC 160.900 ; (2) an immunization for routine use recommended by the Advisory Committee on Immunization Practices (ACIP) and listed on the current immunization schedules of the Centers for Disease Control and Prevention (CDC), adopted by reference in 7 AAC 160.900 ; (3) evidence-informed preventive care and screening based on the Health Resources and Services Administration (HRSA), Women's Preventive Services Guidelines, adopted by reference in 7 AAC 160.900 ; and (4) an item, a service, and an immunization that is intended to prevent or mitigate coronavirus disease 2019 (COVID-19) and that is (i) an evidence-based item or service with an A or B rating by the United States Preventive Services Task Force (USPSTF); or (ii) an immunization recommended by the Advisory Committee on Immunization Practices (ACIP) and adopted by the director of the Centers for Disease Control and Prevention (CDC). (b) Wellness exams are limited to one each state fiscal year. Article 22 Services for Justice-Involved Youth 7 AAC 110.850. Scope of screening and diagnostic services for justice-involved youth. The department will pay for a screening or diagnostic service provided to a justice-involved youth within 30 days of the individual's release from incarceration as an inmate of a public institution or in the post-release period, as those periods are described in 42 U.S.C. 1396a(a)(84)(D)(i). In this section, a service may include (1) a screening as set out under 42 U.S.C. 1396a(a)(84)(D)(i); (2) a necessary diagnostic assessment that meets the requirements of 42 U.S.C. 1396a(a)(84)(D)(i); or (3) an additional service if (A) a provider identified in 7 AAC 110.205 (a) that conducts covered screenings and assessments determines that the additional service is medically necessary; and (B) the provider receives applicable prior authorization from the department. 7 AAC 110.855. Screening services for justice-involved youth. (a) To be covered under 7 AAC 105 - 7 AAC 160 , a screening for a justice-involved youth must be performed by one or more of the providers enrolled under 7 AAC l 10.205(a). (b) To be covered under this section, a screening service may only be provided during the time period set out in 7 AAC 110.850 . (c) To be covered under 7 AAC 105 - 7 AAC 160 , a screening for a justice-involved youth may include (1) a comprehensive medical screening, including a behavioral health screening; (2) a dental screening; (3) a vision screening, including a screening that results in a referral to a vision care services provider upon release from a public institution; or (4) a hearing screening and, if medically necessary, referral for diagnosis and treatment of a defect in hearing upon release from a public institution. 7 AAC 110.860. Covered diagnostic assessments for justice-involved youth. The department will pay for a diagnostic assessment recommended as a result of a screening provided to a justice-involved youth if that assessment is conducted as part of the mandatory services within the definition of "medical assistance" in 42 U.S.C. 1396d(a). Chapter 115 Medicaid Coverage; Therapies and Related Services Article 1 Occupational Therapy Services 7 AAC 115.100. Occupational therapy provider enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing outpatient occupational therapy services, a provider must be an (1) occupational therapist who (A) is enrolled in accordance with 7 AAC 105.210 ; (B) provides documentation of an active license to practice occupational therapy in the jurisdiction in which the individual provides services; if services are provided in this state, the individual must hold an active license under AS 08.84 ; and (C) if providing occupational therapy services out of state, is enrolled in the Medicaid program in the jurisdiction in which the individual provides services; or (2) outpatient occupational therapy program operated by a tribal health program. (b) The department will pay an occupational therapist for services provided in the state by a occupational therapy assistant if the occupational therapy assistant has (1) an active license to practice as an occupational therapy assistant under AS 08.84 ; and (2) enrolled separately with the department as a rendering provider under 7 AAC 105.210 . (c) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing occupational therapy assistant services out of state, an out-of-state occupational therapy assistant must (1) have an active license to practice as an occupational therapy assistant in the jurisdiction in which services are provided; (2) provide proof of enrollment as a Medicaid provider in the jurisdiction in which the services are provided or documentation from that jurisdiction showing that occupational therapy assistants are not enrolled as Medicaid providers in that jurisdiction; and (3) be enrolled separately with the department as a rendering provider under 7 AAC 105.210 . 7 AAC 115.110. Occupational therapy services. (a) The department will pay for occupational therapy services and supplies (1) that are identified in the Fee Schedule for Therapy Services, adopted by reference in 7 AAC 160.900 ; and (2) if those services, except the initial evaluation, are (A) prescribed by a physician, an advanced practice registered nurse, a physician assistant, or another licensed health care professional, within the scope of the practitioner's license; (B) within the scope of practice of an occupational therapist or occupational therapy assistant; (C) provided by or under the direction of an occupational therapist who is enrolled under 7 AAC 105 - 7 AAC 160 ; (D) provided in accordance with the initial evaluation conducted under 7 AAC 115.120 (a) and treatment plan developed by the occupational therapist under 7 AAC 115.120 (b); and (E) documented in a progress note to include start and stop times for time-based billing codes used as provided in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900 . (b) The department will not pay for occupational therapy services for an individual 21 years of age or older that are for maintenance of bodily function, swimming therapy, or weight loss. (c) The department will not pay for the services provided by an occupational therapist aide. (d) The department will pay for maintenance occupational therapy services related to conditions caused by developmental disabilities or developmental delay provided to a recipient under 21 years of age if the services prevent a condition from worsening or the development of an additional health problem. (e) An occupational therapy provider enrolled under this section may request payment for select medically necessary durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200 (a)(2) listed on the Fee Schedule for Therapy Services, adopted by reference in 7 AAC 160.900 , if the item is furnished to a recipient and dispensed by the occupational therapist in the standard course of therapy within the scope of that professional's license. (f) For an individual 21 years of age or older, the department will pay for (1) two units of physical and occupational therapy evaluation services combined each state fiscal year; (2) 30 units of physical and occupational therapy services combined each state fiscal year; and (3) additional units of occupational therapy services if the department gives prior authorization based upon medical justification submitted by the provider. 7 AAC 115.120. Occupational therapy evaluation and treatment plan.