This chapter governs Medicaid enrollment, billing, and payment conditions for ambulatory surgical centers, federally qualified health centers (FQHCs), and rural health clinics in Alaska. It sets out enrollment requirements, covered service categories, reporting obligations, and audit procedures for these facility types. Behavioral health services (e.g., psychotherapy, psychiatric diagnostic interviews) are covered only as a component of FQHC/rural health clinic encounter-rate billing, not as a standalone behavioral health facility license. No behavioral health facility licensing or operating standards are established here.
View official source7 AAC 140.100. Ambulatory surgical center enrollment requirements. To be eligible for payment under 7 AAC 105 - 7 AAC 160 for ambulatory surgical center services, an ambulatory surgical center must (1) be enrolled in the Medicaid program under 7 AAC 105.210 ; (2) have a system to transfer recipients requiring emergency admittance or overnight care to a licensed, Medicaid-enrolled facility following any surgical procedure performed at the ambulatory surgical center; (3) have a department-approved utilization review plan under 7 AAC 160.140 ; and (4) except for ambulatory surgical centers operated by a tribal health program under 7 AAC 155.010 , comply with the requirements of 7 AAC 150 . 7 AAC 140.105. Ambulatory surgical center services. (a) To be covered under 7 AAC 105 - 7 AAC 160 , ambulatory surgical center services must be (1) preventive, diagnostic, therapeutic, rehabilitative, or palliative; (2) directly related to a surgical procedure provided to an outpatient by or under the direction of a physician or dentist; (3) provided in an ambulatory surgical center; and (4) listed in the Ambulatory Surgical Centers (ACS) Approved HCPCS Codes and Payment Rates, adopted by reference in 7 AAC 160.900 . (b) The department will pay for use of the ambulatory surgical center to perform dental services covered by the department under 7 AAC 110.145 - 7 AAC 110.155 , if use of the center is medically necessary. (c) An ambulatory surgical center may not provide overnight services. (d) An ambulatory surgical center must submit a claim to the department for services provided by the ambulatory surgical center separately from submitting a claim to the department for the services of physicians, anesthesiologists, radiologists, and dentists. 7 AAC 140.110. Ambulatory surgical center reports. The department may request a copy of a full operative report, an interpretation of any film, or a pathologist's report on tissue that is removed. When a procedure requires an operative or pathologist's report or particular explanation or interpretation before payment, payment to the ambulatory surgical center is subject to receipt of the report, explanation, or interpretation for evaluation by the department. 7 AAC 140.200. Health clinic enrollment and reporting. (a) The department will pay a health clinic for services provided to a recipient if the health clinic (1) meets the enrollment and reporting requirements of 42 C.F.R. 405.2400 - 405.2444, adopted by reference in 7 AAC 160.900 ; (2) is a federally qualified health center that meets the requirements of 7 AAC 140.205 or a rural health clinic that meets the requirements of 7 AAC 140.210 ; (3) is enrolled as a Medicare provider; (4) is enrolled as a federally qualified health center or rural health clinic in accordance with 7 AAC 105.210 ; (5) is not enrolled as another type of Medicaid provider of primary care or ambulatory services provided by the health clinic; (6) employs staff who meet the individual provider enrollment requirements for each service that the clinic provides if enrollment is required for that type of provider under 7 AAC 105 - AAC 160; and (7) is enrolled as follows if the health clinic is providing those services: (A) as a dental provider under 7 AAC 110.140 ; (B) as a dispensing pharmacy provider under 7 AAC 120.100 ; (C) as a nurse midwife under 7 AAC 110.100 or direct-entry midwife under 7 AAC 110.180 , if providing professional services associated with labor and delivery. (b) Each permanent site operated by a health clinic must be separately enrolled and meet the requirements of this section. In this subsection, "permanent site"; (1) means a fixed, brick-and-mortar location; (2) does not include a temporary location where services are provided on a onetime or occasional basis, such as a health fair, school, or fish camp. (c) For each site where it operates, a health clinic shall maintain sufficient financial records and statistical data to allow the department to identify and verify the costs and charges associated with providing services at each site. (d) On or before the last day of the fifth month after the close of its fiscal year, a health clinic shall file an annual year-end report, even if the clinic did not provide medical services to recipients during that fiscal year. The annual year-end report must contain the items listed in the definition of "year-end report" in 7 AAC 150.990 , except that (1) worksheet A of the Medicare cost report must include separate cost centers for licensed marital and family therapists and for licensed professional counselors; (2) Medicare home office cost statements are not required; (3) the required reconciliation of the post-audit working trial balance must be to the Medicare cost report worksheets A, A-1, and A-2; reconciliation may not be made to the Medicare cost report worksheets A-8, C, and G series; (4) the report must also include a worksheet detailing the total number of visits for the clinic's fiscal year; the worksheet must include visits for dental, licensed marital and family therapist, licensed professional counselor, and other ambulatory services; (5) full-time-equivalent numbers must be reported separately for a licensed marital and family therapist or licensed professional counselor following the same calculation requirements as other rendering providers on Worksheet S-3 Part Ill of the Medicare cost report; and (6) rural health clinics may provide reviewed financial statements meeting the requirements of 7 AAC 150.190 (j)(3)(A) and (B) instead of audited financial statements. (e) If no change in the scope of services occurred during the health clinic fiscal year, and the health clinic does not intend to request a change, the health clinic shall submit to the department, on or before the last day of the fifth of the month after the close of that fiscal year, a written statement indicating that no change in the scope of services occurred or is being requested. (f) If a change in scope of services occurred during the health clinic fiscal year, the health clinic shall submit to the department the additional reports listed in this subsection. The data contained in these reports will be used to evaluate the change in scope of service request made under 7 AAC 145.700 (f), to adjust the health clinic payment rates in accordance with that subsection, and to ensure, in accordance with 7 AAC 145.700 (c)(4), that the prospective payment rate does not exceed upper payment limits. The reports must be submitted on or before the last day of the fifth month after the close of the health clinic fiscal year during which the change in the scope of services occurred, and on or before the last day of the fifth month after 12 continuous months of operation with the change. The reports must include the following: (1) a worksheet detailing the total number by which visits increased or decreased for the clinic's fiscal year due to the change in the scope of services; (2) a narrative report that (A) identifies the date the change in the scope of services occurred; and (B) describes the type of change in the scope of services; (3) a spreadsheet that details the costs that are associated with the change in the scope of services and reported on the Medicare cost report; the spreadsheet must (A) identify the working trial balance, account numbers, and cost centers; and (B) list all expense amounts associated with the change in the scope of services. (g) If the facility receives an extension for filing the Medicare cost report from the Medicare intermediary, the facility must forward a copy of the intermediary's letter that grants the extension to the facility to the department. The department will then grant an extension for the year-end report and the change-in-scope report to coincide with the due date given by the Medicare intermediary. Otherwise, for good cause shown to the department's satisfaction, the department will grant a 30-day extension of the due date for submitting the information required under (d) - (f) of this section. In order to receive an extension from the department, a health clinic must submit to the department an extension request in writing before the due date. For purposes of this subsection, "good cause" (1) means circumstances beyond the control of the health clinic that cause the reporting due date to be missed by several days; and (2) includes natural disasters, hazardous weather, illness of the individual making the request, or specific medical emergencies that preclude timely submission. (h) The department will withhold 20 percent of the payment due to a health clinic if the clinic fails to submit complete information as required in (d) - (f) of this section. The department will restore, without interest, a payment withheld under this subsection, if the health clinic submits complete information as required in (d) - (f) of this section. (i) The department may conduct audits, perform special analysis, and review the records of a health clinic to verify compliance with Medicare and Medicaid laws, audit claims for payment submitted or paid, and make adjustments based on audits to a health clinic's payment rate. A health clinic shall provide to the department financial and all other information regarding Medicaid claims for services provided to eligible recipients, shall provide Medicare cost reports upon request, and shall provide access to all facilities and records. (j) A health clinic may terminate its agreement to participate as a rural health clinic or a federally qualified health center by submitting a written notice to the department and identifying a termination date not less than 30 days after submitting the notice of termination. (k) In this section, (a)(1) and (3) and (d) - (i) of this section do not apply to a federally qualified health center that elects to be reimbursed under 7 AAC 155.010 (1). 7 AAC 140.205. Federally qualified health centers. (a) To qualify as a federally qualified health center under 7 AAC 140.200 and this section and for payment under 7 AAC 145.700 , a provider must meet at least one of the following eligibility requirements for the entire period for which Medicaid services are rendered: (1) a provider is receiving a grant under 42 U.S.C. 254b; (2) a provider is receiving money from a grant under (1) of this subsection under a contract with the grant recipient, and the provider also meets the requirements to receive that type of grant; (3) a provider is determined by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), to meet the requirements for receiving a grant under (1) of this subsection; (4) a provider is a tribal health program. (b) In addition to the requirements of 7 AAC 140.200 , to enroll with the department, a federally qualified health center that is enrolled (1) under (a)(1), (2), or (3) of this section must (A) participate as a federally qualified health center in accordance with this section and 7 AAC 145.700 , 42 C.F.R. 405.2430 - 405.2452, and 42 C.F.R. Part 491, adopted by reference in 7 AAC 160.900 ; and (B) provide the department with a letter from CMS, certifying the entity as a federally qualified health center provider, and must provide a copy of its grant notice; (2) under (a)(4) of this section must participate as a federally qualified health center in accordance with this section and 7 AAC 145.700 and 42 C.F.R. 405.2446 - 405.2452, adopted by reference in 7 AAC 160.900 . 7 AAC 140.210. Rural health clinics. To qualify as a rural health clinic under 7 AAC 140.200 and this section and for payment under 7 AAC 145.700 , a provider must be an entity that the department has certified under 42 C.F.R. Part 491 as being in compliance with 42 C.F.R. 405.2400 - 405.2417, adopted by reference in 7 AAC 160.900 . 7 AAC 140.215. Health clinic services and payment conditions. (a) The department will pay a health clinic for providing services under (b) - (e) of this section rendered to a patient of the clinic by an employee or a contract worker of the clinic. Except as otherwise provided in this section, the department will pay a provider for services under this section in accordance with the payment rate established in 7 AAC 145.700 , or 7 AAC 155.010 , as applicable. (b) The department will pay for primary care services provided by a physician, a physician assistant, or an advanced practice registered nurse acting within the scope of that individual's license to practice. The department will not pay a federally qualified health center under the rate methodology established in 7 AAC 145.700 for services that the department determines to be incidental to primary care services, including laboratory services, x-ray services, and supplies. (c) The department will pay for ambulatory services under 7 AAC 105 - 7 AAC 160 , including (1) vision services under 7 AAC 110.705 ; (2) speech-language pathology services under 7 AAC 115.410 ; (3) hearing services under 7 AAC 115.520 and 7 AAC 115.530 ; (4) EPSDT screening and EPSDT services under 7 AAC 110.205 and 7 AAC 110.210 ; (5) podiatry services under 7 AAC 110.505 ; (6) nutrition services under 7 AAC 110.275 and 7 AAC 110.280 ; (7) private-duty nursing services under 7 AAC 110.525 ; (8) hospice services under 7 AAC 140.275 and 7 AAC 140.280 ; (9) family planning services under 7 AAC 110.230 ; (10) physical therapy services under 7 AAC 115.310 ; (11) occupational therapy services under 7 AAC 115.110 ; (12) chiropractic services under 7 AAC 110.120 ; and (13) nonprimary care services that are provided in a hospital by a rural health clinic physician, physician assistant, or advanced practice registered nurse acting within the scope of that individual's license to practice. (d) The department will separately pay a health clinic for dental services covered under 7 AAC 110.145 - 7 AAC 110.155 provided by a dentist who is enrolled separately under 7 AAC 110.140 . (e) The department will pay the established encounter rate to a health clinic for the behavioral health services identified in Table 1-1. Procedure Codes: Mental Health Services of the Federally Qualified Health Center/Rural Health Clinic Services section of the Alaska Provider Billing Manual, adopted by reference in 7 AAC 160.900 , if those services are provided to a recipient by a psychologist, clinical social worker, marital and family therapist, or professional counselor acting within the scope of that individual's license to practice. Behavioral health services covered under this subsection include (1) psychiatric diagnostic interview procedures; (2) psychological testing and examination services; (3) individual psychotherapy; (4) group psychotherapy; (5) family psychotherapy; and (6) health and behavior assessment and intervention services. (7) screening and brief intervention services. (f) In accordance with the relevant fee schedule established under 7 AAC 145.050 , the department will separately pay a health clinic eligible under 7 AAC 140.205 (a)(1), (2), or (3) for labor and delivery services provided by a physician, a physician assistant, or an advanced practice registered nurse, including a nurse midwife, who has separately enrolled under 7 AAC 105 - 7 AAC 160 . The department will pay a health clinic eligible under 7 AAC 140.205 (a)(4) in accordance with 7 AAC 155.010 . (g) The department will separately pay a health clinic for pharmacy services and for prescription drugs provided by the health clinic under 7 AAC 120.110 if the health clinic is enrolled as a dispensing provider in accordance with 7 AAC 120.100 . The department will pay a provider under this subsection in accordance with the rates established in 7 AAC 145.400 and 7 AAC 145.410 . (h) The department will not pay a health clinic eligible under 7 AAC 140.205 (a)(1), (2), or (3) for (1) services or supplies that a health clinic routinely provides to individuals other than Medicaid-eligible recipients; (2) services or supplies that the health clinic routinely furnishes for free or without regard to the recipient's ability to pay; or (3) services provided off-site of the health clinic, except as provided in 7 AAC 140.220 ; this paragraph does not apply to a federally qualified health center. 7 AAC 140.220. Health clinic services provided off-site. (a) The department will not pay a health clinic for services provided off-site unless (1) the health clinic patient is homebound as determined under (b) of this section and if all of the following conditions are met: (A) the United States Department of Health and Human Services has determined that a shortage of home health agencies exists in the area; (B) services are furnished by a registered nurse, a licensed practical nurse, or a licensed vocational nurse who is employed by, or receives compensation for the services from, the clinic; (C) the services are furnished under a written plan of treatment that is (i) established and reviewed at least every 60 days by a supervising physician of the health clinic or established by an advanced practice registered nurse or a physician assistant and reviewed at least every 60 days by a supervising physician; and (ii) signed by the advanced practice registered nurse, the physician assistant, or the supervising physician of the health clinic; (D) the nursing care coverage is limited as specified in 42 C.F.R. 405.2416(b) and (c), adopted by reference in 7 AAC 160.900 ; (2) a rural health clinic physician, acting within the scope of the physician's license to practice, provides the services in a hospital or nursing facility; (3) a rural health clinic physician assistant or rural health clinic advanced practice registered nurse, acting within the scope of that individual's license to practice, provides the services in a hospital; or (4) a federally qualified health center physician, physician assistant, or advanced practice registered nurse, acting within the scope of the individual's license to practice, provides the services in a nursing facility. (b) A health clinic patient is homebound if, due to the individual's medical or health condition, the individual is confined to the individual's residence, or cannot leave the residence without considerable effort. The department will not disqualify an individual from being considered homebound for infrequent absences of short duration from the residence, including absences to attend religious services, or for absences from the residence in order to receive health care treatment, including participation in therapeutic or medical treatment as part of adult day services provided under 7 AAC 130.250 by a provider that is certified under 7 AAC 130.220 . The department will not consider an individual to be homebound if the individual's residence is a hospital or long-term care facility. (c) This section does not apply to a federally qualified health center. 7 AAC 140.229. Definitions. In 7 AAC 140.200 - 7 AAC 140.229 , (1) "ambulatory services" means noninstitutional services that are payable under Medicaid and provided in accordance with this chapter; "ambulatory services" includes (A) visual care; (B) speech; (C) hearing; (D) language; (E) EPSDT; (F) podiatry; (G) nutrition; (H) private duty nursing; (I) hospice care; (J) family planning; (K) physical therapy; (L) occupational therapy; (M) chiropractic; and (N) services that are not primary care services, that are provided by a physician, physician assistant, or advanced practice registered nurse, that are within the scope of that individual's license to practice, and that are (i) provided in or by a hospital; or (ii) laboratory or x-ray services only; (2) "change in the scope of service" has the meaning given in 7 AAC 145.700 (k); (3) "cost center" has the meaning given in 7 AAC 150.990 ; (4) "health clinic" (A) means a federally qualified health center or a rural health clinic; (B) does not include a private or nonprofit medical practice or clinic that is not a federally qualified health center or rural health clinic; (5) "visit" has the meaning given in 7 AAC 145.739 . 7 AAC 140.270. Hospice care provider enrollment. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing hospice care services, the provider must (1) be enrolled in the Medicaid program under 7 AAC 105.210 ; (2) be a public or private organization that the department has certified as a hospice for the purposes of the Medicare program under 42 C.F.R. Part 418, adopted by reference in 7 AAC 160.900 ; and (3) provide hospice care services for periods of at least 210 days. (b) If the hospice care provider enrolled under (a) of this section employs individuals to provide professional or specialized services, those employees must individually meet any applicable state licensing requirements. (c) The department will not enroll a hospice care organization that is located out of state. 7 AAC 140.275. Hospice care services. (a) Before the department will give prior authorization to and pay for hospice care services provided to a recipient in the recipient's place of residence, the department must receive, no more than eight days after hospice care begins, (1) a certification, signed by the recipient's attending physician and the medical director of the hospice, that the recipient's medical prognosis is a life expectancy of six months or less if the illness runs its normal course; (2) a copy of the recipient's care plan described in (d) of this section; and (3) an election statement, signed by the recipient or the recipient's representative, that includes (A) the name of the designated hospice; (B) an acknowledgment by the recipient, or the recipient's representative, of an understanding of hospice care; (C) the effective date of the election; (D) an acknowledgment by the recipient, or the recipient's representative, that for the duration of care, the recipient waives the recipient's rights to hospice care by any other hospice unless arranged through the designated hospice, and waives the recipient's rights to any other Medicaid-covered services related to the recipient's terminal illness except for those provided by the designated hospice, an alternative hospice under arrangement with the designated hospice, or the recipient's attending physician; (E) an acknowledgment of the recipient's option to revoke the election of hospice care at any time; and (F) an acknowledgment of the recipient's option to elect to change the designation of the hospice by submitting to both hospices a signed statement indicating the hospice from which care has been received, the newly designated hospice, and the date the change is effective; the recipient may only elect to change the designation of the hospice once in each election period as described in 42 C.F.R. 418.21 and 418.30, adopted by reference in 7 AAC 160.900 . (b) A recipient eligible for Medicare and Medicaid must make an election of a hospice, a designation of change of a hospice, or a revocation of a hospice simultaneously for both programs. (c) The following hospice care services are not paid separately from payments made for routine home care, continuous home care, inpatient respite care, or general inpatient care, as provided in 7 AAC 145.690 : (1) preparation of a written plan of care that meets the requirements of (d) of this section; (2) a service rendered that is consistent with the written plan of care; (3) nursing care provided under the direction of a registered nurse; nursing care must be routinely provided by employees of the hospice; (4) medical social services rendered by a social worker under the direction of a physician; medical social services rendered by a social worker under the direction of a physician must be routinely provided by employees of the hospice; (5) physical, occupational, and speech therapy; (6) durable medical equipment, medical supplies, and biologicals and drugs that are used primarily for the relief of pain and symptom control of the terminal illness; (7) home health aide and homemaker services provided in the recipient's home under the direction of a registered nurse; (8) counseling services provided to the recipient, family members, or caregiver for the purpose of enabling the family or caregiver to provide care, or aiding in adjustment to the recipient's approaching death, and up to one year following the death of the recipient; counseling services described in this paragraph must be routinely provided by employees of the hospice. (d) A hospice care provider shall prepare a written plan of care that contains an initial plan of care expanded to a comprehensive plan of care. Before hospice service begins, a written initial plan of care must be completed by a registered nurse or physician in cooperation with at least one member of the interdisciplinary group. A comprehensive plan of care must be reviewed and updated at intervals, specified in the plan, by the hospice medical director or the recipient's attending physician, and by the interdisciplinary group. The plan must include an assessment of the recipient's needs and state in detail the scope and frequency of services needed to meet the recipient's and family's needs. (e) Nursing care, physician services, medical social services, and counseling are core hospice services and must be routinely provided by hospice employees. Physician services provided by the hospice must also meet the general medical needs of the recipient to the extent that the needs are not met by the recipient's attending physician. (f) Continuous home care is to be provided only during a period of crisis in which a recipient requires constant care to reduce or manage acute medical symptoms as necessary to maintain a recipient at home. To be paid as continuous home care, a minimum of eight hours of care described in 42 C.F.R. 418.204, adopted by reference in 7 AAC 160.900 , must be provided in each 24-hour period, and may be supplemented with homemaker and home health aide services; more than half of the continuous home care hours must be nursing care. If care less skilled than nursing services is required on a continuous basis to maintain the recipient at home, that care will be paid as routine home care. (g) The interdisciplinary group required by (d) of this section must include a doctor of medicine or osteopathy, a registered nurse, a social worker, and a counselor. 7 AAC 140.280. Hospice care for individuals under 21 years of age. (a) Except as otherwise provided in this section, the department may enroll a hospice care provider and pay for hospice care services for a recipient under 21 years of age in the same manner as in 7 AAC 140.270 - 7 AAC 140.275 and 7 AAC 145.690 . In addition to satisfying the requirements in 7 AAC 140.275 , and no earlier than 12 months before hospice care services begin, the recipient must have had an EPSDT screening that meets the requirements in 7 AAC 110.205 for coverage. (b) In addition to the hospice care services eligible for payment under 7 AAC 140.275 (c), a recipient under 21 years of age may receive private-duty nursing services rendered by or under the supervision of a registered nurse in a recipient's home. The department will pay for those private-duty nursing services provided in a recipient's home at the in-state rate established under 7 AAC 145.250 . The department will not pay for out-of-state private-duty nursing services under this section. 7 AAC 140.289. Definitions. In 7 AAC 140.200 - 7 AAC 140.289 , (1) "continuous home care" means care provided during a period of crisis in which a recipient requires constant care to reduce or manage acute medical symptoms as necessary to maintain a recipient at home; (2) "general inpatient care" means care provided in a participating hospice inpatient unit or a participating general acute care hospital or nursing facility that meets the standards for staffing and recipient areas in 42 C.F.R. 418.98 or 42 C.F.R. 418.100, adopted by reference in 7 AAC 160.900 , for procedures necessary for pain control or acute or chronic symptom management that cannot feasibly be provided in another setting; (3) "inpatient respite care" means a short-term admission of no more than five days for inpatient care in a facility that meets the standards in 42 C.F.R. 418.98(b), adopted by reference in 7 AAC 160.900 , in order to provide relief to the caregiver; "inpatient respite care" does not include care provided to a recipient residing in a long-term care facility; (4) "interdisciplinary group" means a group of individuals designated by a hospice who provide or supervise the care and services offered by the hospice; (5) "routine home care" means any combination of the services listed in 7 AAC 140.275 (c)(1) - (8) provided to a recipient electing hospice care that are not provided at the level and intensity of continuous home care. 7 AAC 140.300. Hospital provider requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing hospital services, a provider must (1) be enrolled as a hospital in accordance with 7 AAC 105.210 ; (2) if located in the state, (A) be licensed under AS 47.32 , except for a hospital operated by a tribal health program; and (B) comply with the requirements of 7 AAC 150 ; (3) if located out of state, meet all applicable licensing and accreditation requirements of the jurisdiction in which the hospital is located; (4) have a department-approved plan of utilization review; and (5) comply with all prior authorization requirements established under 7 AAC 105 - 7 AAC 160 . (b) The provisions of 7 AAC 140.300 - 7 AAC 140.325 apply to all general acute care hospital services, including inpatient, outpatient, and emergency room services. Except as otherwise provided in 7 AAC 105 - 7 AAC 160 , 7 AAC 140.300 - 7 AAC 140.325 do not apply to inpatient or outpatient psychiatric facility or residential psychiatric treatment center services. 7 AAC 140.305. Admission to a hospital. The department will pay for inpatient hospital services only if the (1) recipient is admitted to the hospital by the written order of a physician or other licensed health care professional authorized to admit a patient to a hospital; (2) recipient requires a general acute care hospital level of care or meets the requirements for administrative-wait bed or swing-bed status; and (3) department gives prior authorization for admission as required under 7 AAC 105 - 7 AAC 160 . 7 AAC 140.310. Covered hospital services. (a) The department will pay for those hospital services for which a revenue code is listed in Section I of the Inpatient/Outpatient Hospital Services section of the Alaska Provider Billing Manual, adopted by reference in 7 AAC 160.900 , and in the Covered Revenue Codes for Outpatient Hospitals and the Covered Revenue Codes for Inpatient Hospitals of the Indian Health Service (IHS)/Tribal Facility Services section of the Alaska Provider Billing Manual, adopted by reference in 7 AAC 160.900 . Some revenue codes are for services that are limited based on recipient age, gender, and eligibility category as otherwise provided in AS 47.07 , 7 AAC 100 , or 7 AAC 105 - 7 AAC 160 . (b) The department will pay for the standard daily hospital service, which includes room, linen service, meals, special diets, general nursing service, medical records and admitting service, use of ordinary hospital equipment and instruments, routine treatments, routine drugs, and routine supplies. (c) The department will pay for the central hospital service, which includes supplies and preparing, handling, and storing supplies. (d) The department will pay a hospital for drugs prescribed by the attending physician or other dispensing provider only if the drugs are administered to the recipient while the patient is receiving care in the hospital. (e) The department will pay for outpatient hospital observation services, not to exceed 48 hours, only if a recipient's condition warrants evaluation. 7 AAC 140.315. Noncovered hospital services. (a) Except as otherwise provided in 7 AAC 105 - 7 AAC 160 , the department will not pay for services (1) identified as noncovered services in 7 AAC 105.110 ; or (2) for which a revenue code is not listed as described in 7 AAC 140.310 (a). (b) Except as otherwise provided in 7 AAC 105 - 7 AAC 160 , the department will not pay a hospital for the following services and procedures: (1) a service that is not within the scope of the facility's licensure, certification, or accreditation; (2) the following services, unless the department gives prior authorization specifically for the service: (A) the dispensing of antabuse; (B) methadone treatment, including the dispensing of methadone; (C) alcohol or drug detoxification or rehabilitation; (3) tobacco cessation therapy and services; however, the department will pay for tobacco cessation products; (4) leaves of absence, including charges for holding a recipient's room or bed, except as described under 7 AAC 140.585 when a recipient is in a hospital's long-term care facility; (5) services and procedures that do not require hospital care, including (A) outpatient special residence charges, rest cures, daily respite care under 7 AAC 130.280 , adult day services, or day care for children; (B) room and board for individuals other than the patient, unless the department gives prior authorization specifically for the service; (C) admission solely for the purpose of medical and dental services, surgical procedures, or diagnostic testing that can be performed on an outpatient basis or in an ambulatory surgical center; however, the department will give prior authorization specifically for a service, procedure, or test if the recipient's (i) current medical condition or physical or mental disabilities are sufficiently severe that performing that service, procedure, or test on an outpatient basis or in an ambulatory surgical center would seriously endanger the recipient's health; or (ii) recent medical history indicates that performing that service, procedure, or test on an outpatient basis or in an ambulatory surgical center would seriously endanger the recipient's health; (D) recipients who do not require or who no longer require acute inpatient care; however, the department will make a payment to the hospital for accommodation when no long-term care bed is available, if the department has approved the level of care appropriate for the recipient in situations involving a swing bed or administrative-wait bed; (E) custodial care related to court commitments; patients confined to a hospital under a court commitment for any reason will be covered for payment only to the extent medical necessity exists for inpatient hospital care; (F) recipients remaining beyond the length of stay authorized under 7 AAC 140.320 ; (G) recipients pending discharge when hospital care is no longer required; (H) days of care due to failure to promptly request or perform necessary diagnostic studies, medical-surgical procedures, or consultations; (I) disability examinations, except that the department will pay for outpatient tests ordered by a physician as part of (i) an initial disability examination in accordance with 7 AAC 40.180 ; or (ii) a review of a disability determination in accordance with 7 AAC 40.190 ; (J) evaluative or periodic checkups, examinations, or immunizations that are connected with the participation in, enrollment in, attendance at, or accomplishment of a program or activity unrelated to the recipient's physical or mental health or rehabilitation, except mammograms; (6) organ transplants and related services, and dental implants, except that the department will make payment for organ transplants and requisite related medical care for (A) kidney and corneal transplants; prior authorization is not required; (B) skin and bone transplants for which the department has given prior authorization; (C) bone marrow transplants for which the department has given prior authorization; (D) liver transplants for which the department has given prior authorization, for persons with biliary atresia or other forms of end-stage liver disease; and (E) heart, lung, and heart-lung transplants for which the department has given prior authorization; (7) weekend stays if admission was made on Friday or Saturday for surgery scheduled on Monday, except for an emergency or situation where the physical or mental condition of the patient necessitates extensive preoperative preparation or therapy; (8) professional fees in addition to those typically charged within specific cost centers, including osteopathic services, and except registered nurse anesthetist services; (9) separately identifiable preventive care services, clinic services, medical social services, and trauma team response activation charges; (10) nursing services and incremental nursing charges assessed in addition to accommodation charges, including private-duty nursing charges; (11) take-home drugs, oxygen, and supplies not otherwise classified; (12) home infusion therapy; (13) miscellaneous home dialysis charges; (14) educational services and supplies; (15) cardiac rehabilitation that exceeds the guidelines in the Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10 (Cardiac Rehabilitation Programs), adopted by reference in 7 AAC 160.900 ; (16) recreational therapy and medical rehabilitation day programs; (17) charges for services or items normally considered part of routine services and optional or special services not directly related to medical care, including (A) private accommodation charges, unless medically necessary; (B) deluxe accommodation charges; (C) patient convenience items; and (D) routine service charges for accommodations that cannot be included in more specific revenue codes; (18) personal services not normally associated with hospital care, including long-distance telephone calls, television rental, guest meals, and personal items. (c) The department will not pay for a service or inpatient stay for which prior authorization is denied, or is required but not obtained, including nonemergency out-of-state services for which prior authorization is not obtained under 7 AAC 105.130 . (d) Repealed 3/19/2014. (e) Except as provided in (f) of this section, the department will not pay a hospital for the following provider-preventable conditions: (1) services and procedures related to a health care-acquired condition as defined in 42 C.F.R. 447.26(b), adopted by reference in 7 AAC 160.900 ; (2) a wrong surgical or other invasive procedure performed on a patient; (3) a surgical or other invasive procedure performed on the wrong body part; (4) a surgical or other invasive procedure performed on the wrong patient. (f) A reduction in payment resulting from a provider-preventable condition identified in (e) of this section will be abrogated in accordance with 42 C.F.R. 447.26(c)(2) or limited in accordance with 42 C.F.R. 447.26(c)(3). The provisions of 42 C.F.R. 447.26(c) are adopted by reference in 7 AAC 160.900 . (g) In this section, "cost center" has the meaning given in 7 AAC 150.990 . 7 AAC 140.320. Length of hospitalization. (a) Except as provided in (b) and (d) of this section, the department will not pay for more than three days of hospitalization for any single admission, except that, for a maternal and newborn hospital stay related to childbirth, the department will not pay for more than 48 hours of inpatient hospitalization for a single recipient following a normal vaginal delivery and no more than 96 hours of inpatient hospitalization for a single recipient following a cesarean delivery. (b) The department will not pay for coverage beyond the days or hours of hospitalization specified in (a) of this section unless the department has given prior authorization for those days or hours under 7 AAC 105.130 . (c) If the department reimburses a provider under the Diagnosis Related Groups (DRG) methodology, the department will use the method specified in 7 AAC 150.250 (a)(4) to calculate the amount that will be reimbursed for the length of stay. (d) If the department reimburses a hospital under the Diagnosis Related Groups (DRG) methodology, the hospital is exempt from the requirements of (b) of this section. 7 AAC 140.325. Billing for hospital services. (a) The quality improvement organization (QIO) certification of necessity for hospital stays over three days or for stays for treatment or procedures on the Select Diagnoses and Procedures Pre-certification List, adopted by reference in 7 AAC 160.900 , must appear on the invoice submitted by the hospital in order to receive payment. The department will pay only for days that are medically necessary and within the scope of Medicaid coverage. If a recipient refuses to leave the hospital at the end of a covered stay, the hospital may bill the recipient for days beyond the noncovered or noncertified portion of the hospital stay. Payment by the department for covered services is considered by the department to be payment in full for those covered services. (b) When a health care-acquired condition or provider-preventable condition described in 7 AAC 140.315 (e) is not present on admission, but is reported as a diagnosis associated with the hospitalization, the hospital must submit a claim identifying the condition, even if the hospital does not seek reimbursement for the hospitalization. 7 AAC 140.350. Inpatient psychiatric hospital provider requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing inpatient psychiatric hospital services, a provider must (1) be enrolled as an inpatient psychiatric hospital in accordance with 7 AAC 105.210 ; (2) if located in this state, (A) be licensed under AS 47.32 and accredited by the Joint Commission; (B) comply with the requirements of 7 AAC 150 ; (3) if located out of state, meet all applicable licensing and accreditation requirements of the jurisdiction in which the inpatient psychiatric hospital is located; and (4) meet the requirements of 7 AAC 140.350 - 7 AAC 140.365 . (b) An inpatient psychiatric hospital provider shall record the results of each required screening, assessment, evaluation, and certification in a written report and include that report in the recipient's medical record. (c) An inpatient psychiatric hospital provider shall provide an accounting for any funds accepted from a patient for safekeeping and shall make that accounting available for inspection by designated department staff and for audit by the department. 7 AAC 140.355. Inpatient psychiatric hospital services. (a) Subject to the admission and prior authorization requirements of 7 AAC 140.360 and plan-of-care requirements of 7 AAC 140.365 , the department will pay for therapeutically appropriate, medically necessary diagnostic and treatment services for recipients who are admitted to an inpatient psychiatric hospital, including the following services: (1) intake assessment; (2) admitting history and physical examination; (3) individual psychotherapy; (4) group psychotherapy; (5) family psychotherapy; (6) pharmacologic management; (7) crisis intervention; (8) medication administration. (b) Psychiatric services provided in an inpatient psychiatric hospital must be provided (1) under the supervision of a psychiatrist licensed under AS 08.64 ; and (2) in a manner consistent with an individual plan of care that meets the requirements of 7 AAC 140.365 and is signed by the supervising psychiatrist. (c) Payment for inpatient psychiatric hospital services is limited to services provided to an individual under 21 years of age or an individual 65 years of age and older. (d) in this section, "admitting history and physical examination" means a comprehensive review and examination of a recipient upon admission to an inpatient psychiatric hospital to determine and record the recipient's (1) medical history; (2) developmental history; (3) social history; (4) present illness or illnesses; (5) basic physical health by means of a complete physical examination; (6) medication history; and (7) allergies, if any. 7 AAC 140.360. Inpatient psychiatric hospital admission. (a) The department will not pay for inpatient psychiatric hospital services unless the department has authorized the recipient's admission. Before the department will authorize admission, the department will verify that the requirements of (b) and (c) of this section are met. (b) Upon admission, an inpatient interdisciplinary team that meets the requirements of (d) of this section must (1) complete a diagnostic evaluation that (A) includes a psychiatric assessment; (B) is performed no more than 60 days before admission or no more than 72 hours after admission; and (C) indicates the need for inpatient psychiatric services; (2) certify in the recipient's medical record that (A) available alternate community resources for ambulatory care do not meet the treatment needs of the recipient, if the recipient is under 21 years of age; (B) proper treatment of the recipient's psychiatric condition requires services on an inpatient basis, as appropriate; and (C) inpatient psychiatric services can reasonably be expected to improve the recipient's condition or prevent further regression; (3) provide to the department (A) the results of the diagnostic evaluation required in (1) of this subsection; (B) the results of a functional assessment; (C) the results of any direct patient observations and assessments obtained following the recipient's referral; and (D) other information from referral sources, other community agencies, and the family, that is relevant to the recipient's condition; and (4) develop a plan of care based upon the information provided under this subsection that meets the requirements of 7 AAC 140.365 . (c) Based on the information received under (b)(3) of this section, the department will determine if the proposed treatment and other services are consistent with the recipient's clinical diagnosis and if they appropriately address the recipient's needs. (d) An inpatient interdisciplinary team that provides the services required in (b) of this section must, by virtue of education and experience, have the capability of assessing the recipient's immediate and long-range therapeutic requirements, developmental priorities, personal strengths, liabilities, and the potential resources of the recipient's family. Except as provided in (f) of this section, an inpatient interdisciplinary team must include (1) either a (A) psychiatrist licensed under AS 08.64 ; (B) psychologist licensed under AS 08.86 who has a doctorate degree in clinical psychology and a physician licensed under AS 08.64 to practice medicine or osteopathy; or (C) physician licensed under AS 08.64 to practice medicine who has specialized training and experience in the diagnosis and treatment of mental diseases and a psychological associate licensed under AS 08.86 ; (2) a representative of the office of the Department of Family and Community Services responsible for children's services if the child is in that subunit's custody, or a representative of the division of the Department of Family and Community Services responsible for juvenile justice if the child is in that division's custody; (3) a clinical social worker licensed under AS 08.95 ; (4) a registered nurse licensed under AS 08.68 who has specialized training or one year's experience in treating mentally ill patients; and (5) depending upon the needs of the recipient, either (A) an occupational therapist licensed under AS 08.84 who has specialized training or one year's experience in treating mentally ill patients; or (B) a psychological associate licensed under AS 08.86 who has a master's degree in clinical psychology. (e) Upon the admission of a recipient under 21 years of age to an inpatient psychiatric hospital, the provider shall arrange for appropriate EPSDT screening services, in accordance with 7 AAC 110.200 - 7 AAC 110.210 . The provider shall ensure that a child has received EPSDT screening (1) no more than the 60 days immediately preceding the date of admission; or (2) no more than five days after the date of admission. (f) Members of the interdisciplinary team of an out-of-state inpatient psychiatric hospital must be licensed by the jurisdiction in which the inpatient psychiatric hospital is located. (g) The department will issue a prior authorization required under this section in accordance with the State of Alaska, Department of Health, Behavioral Health Inpatient Psychiatric Review Provider Manual, adopted by reference in 7 AAC 160.900 . 7 AAC 140.365. Inpatient psychiatric hospital plan of care. (a) The individual plan-of-care established by the inpatient interdisciplinary team in accordance with 7 AAC 140.360 (b)(4), and a subsequent plan of care review, must (1) be comprehensive and in writing; (2) be developed based upon a diagnostic evaluation as required in 7 AAC 140.360 (b)(1); (3) be formulated in consultation with the recipient and the recipient's family, guardian, or other individual into whose care or custody the recipient will be released following discharge; (4) document individualized treatment objectives and prescribe an integrated program of appropriate therapies, activities, and experiences designed to develop the recipient's ability to function independently in the recipient's own environment; (5) include appropriate treatments that are reasonably expected to improve the recipient's condition to the extent that inpatient psychiatric services will become unnecessary; for a recipient under 21 years of age, the treatment plan must include family psychotherapy unless family psychotherapy is contraindicated; and (6) include a discharge plan prepared at the time of admission and updated during the recipient's inpatient stay as the recipient's mental health service needs change, that specifies the approximate date for discharge, the recipient's anticipated post-discharge service needs, the recipient's prospective community-based service providers, and other provisions necessary for the transition to a less restrictive environment. (b) The department will review a recipient's plan of care every 30 days to determine whether the inpatient psychiatric hospital services provided are or were required. The department may make recommendations as to necessary adjustments in a plan of care based on the recipient's response to treatment. 7 AAC 140.400. Residential psychiatric treatment center provider requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing residential psychiatric treatment center (RPTC) services, a provider must (1) be enrolled as an RPTC in accordance with 7 AAC 105.210 ; (2) if located in this state, be licensed by the department under AS 47.32 ; (3) if located out of state, meet the licensing and accreditation requirements of the jurisdiction in which the RPTC is located; (4) be accredited by The Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, or the Council on Accreditation of Services for Families and Children as a residential psychiatric treatment center for care of children under 21 years of age; (5) comply with the requirements of 7 AAC 140.400 - 7 AAC 140.415 ; (6) comply with 42 C.F.R. 483.350 - 483.376, adopted by reference in 7 AAC 160.900 , governing the use of restraint and seclusion; and (7) provide basic residential care and services that include (A) dwelling space provided in separate buildings or units with no more than 60 residential beds per building and no more than 30 beds provided for sleeping accommodation per unit; if the residential unit is part of a larger facility, the residential unit must be a separate and distinct area from other designated psychiatric or treatment units; and (B) equipment, supplies, maintenance, and insurance used by residents for program activities and case-specific services. (b) The results of required screenings, assessments, evaluations, and certifications must be recorded separately in a written report and included in the recipient's medical record. (c) An RPTC shall provide an accounting for any funds accepted from the patient for safekeeping. This accounting must be available for inspection by designated department staff and for audit by the department. (d) The department may (1) deny payment to, deny enrollment to, or disenroll a residential psychiatric treatment center in the Medicaid program if the department determines that the facility used a service under 7 AAC 140.415 (d); (2) deny enrollment to or disenroll a residential psychiatric treatment center in the Medicaid program if the department determines that the facility (A) is under investigation, or has been disciplined, by another state for a violation that is substantially similar to a violation under 7 AAC 105.400 ; (B) is no longer accredited by an organization listed in (a)(4) of this section; or (C) does not meet the applicable requirements under 7 AAC 105.120 (b)(2) and (3), if the facility is located out of state. 7 AAC 140.405. Residential psychiatric treatment center admission. (a) The department will not pay for RPTC services unless the department has authorized the recipient's admission. Before the department will authorize admission, the department will verify that the requirements of (b) and (c) of this section are met. (b) Upon admission, an inpatient interdisciplinary team that meets the requirements of (d) of this section must (1) complete a diagnostic evaluation that (A) includes a psychiatric assessment; (B) is performed before admission or no more than seven days after admission; and (C) indicates the need for RPTC services; (2) certify in the recipient's medical record that (A) available alternate community resources for ambulatory care do not meet the treatment needs of the recipient; (B) proper treatment of the recipient's psychiatric condition requires services on an inpatient or residential basis, as appropriate; and (C) RPTC services can reasonably be expected to improve the recipient's condition or prevent further regression; (3) provide to the department (A) the results of the diagnostic evaluation required in (1) of this subsection; (B) the results of a functional assessment; (C) the results of any direct patient observations and assessments obtained following the recipient's referral; (D) other information from referral sources, other involved community agencies, and the family, that is relevant to the recipient's condition; and (4) develop a plan of care based upon the information provided under this subsection that meets the requirements of 7 AAC 140.410 . (c) Based on the information received under (b)(3) of this section, the department will determine if the proposed treatment and other services are consistent with the recipient's clinical diagnosis and if they appropriately address the recipient's needs. (d) An inpatient interdisciplinary team that provides the services required in (b) of this section must, by virtue of education and experience, have the capability of assessing the recipient's immediate and long-range therapeutic requirements, developmental priorities, personal strengths, liabilities, and the potential resources of the recipient's family. Except as provided in (f) of this section, an inpatient interdisciplinary team must include (1) either a (A) psychiatrist licensed under AS 08.64 ; (B) psychologist licensed under AS 08.86 who has a doctorate degree in clinical psychology and a physician licensed under AS 08.64 to practice medicine or osteopathy; or (C) physician licensed under AS 08.64 to practice medicine who has specialized training and experience in the diagnosis and treatment of mental diseases and a psychological associate licensed under AS 08.86 ; (2) a representative of the office of the Department of Family and Community Services responsible for children's services if the child is in that office's custody, or an appropriate representative of the division of the Department of Family and Community Services responsible for juvenile justice if the child is in that division's custody; (3) a clinical social worker licensed under AS 08.95 ; (4) a registered nurse licensed under AS 08.68 who has specialized training or one year's experience in treating mentally ill patients; and (5) depending upon the needs of the recipient, either (A) an occupational therapist licensed under AS 08.84 who has specialized training or one year's experience in treating mentally ill patients; or (B) a psychological associate licensed under AS 08.86 who has a master's degree in clinical psychology. (e) Upon the admission of a recipient under 21 years of age to an RPTC, the RPTC shall arrange for appropriate EPSDT screening services, in accordance with 7 AAC 110.200 - 7 AAC 110.210 . The RPTC must ensure that a child has received EPSDT screening (1) no more than the 60 days immediately preceding the date of admission; or (2) no more than five days after the date of admission. (f) Members of the interdisciplinary team of an out-of-state RPTC must be licensed by the jurisdiction in which the RPTC is located. (g) The department will issue a prior authorization required under this section in accordance with the State of Alaska, Department of Health, Behavioral Health Inpatient Psychiatric Review Provider Manual, adopted by reference in 7 AAC 160.900 . 7 AAC 140.410. Residential psychiatric treatment center plan of care. (a) The individual plan of care established by the inpatient interdisciplinary team in accordance with 7 AAC 140.405 (b)(4) must (1) be comprehensive and in writing; (2) be developed based upon a diagnostic evaluation as required in 7 AAC 140.405 (b)(1); (3) be formulated in consultation with the recipient and the recipient's family, guardian, or other individual to whose care or custody the recipient will be released following discharge; (4) document treatment objectives and prescribe an integrated program of appropriate therapies, activities, and experiences designed to develop the recipient's ability to function independently in the recipient's own environment; (5) include appropriate treatments that are reasonably expected to improve the recipient's condition to the extent that RPTC services will become unnecessary; and (6) include a discharge plan prepared at the time of admission and updated during the recipient's inpatient stay as the recipient's mental health service needs change, that specifies the approximate date for discharge, the recipient's anticipated post-discharge service needs, the recipient's prospective service providers, and other provisions necessary for the transition to a less restrictive environment. (b) The department will review a recipient's plan of care to determine whether the RPTC services provided are or were required. The department may make recommendations as to necessary adjustments in a plan of care based on the recipient's response to treatment. The department will do a review every 60 days. 7 AAC 140.415. Residential psychiatric treatment center services. (a) Subject to the requirements of admission and prior authorization requirements of 7 AAC 140.405 and plan-of-care requirements of 7 AAC 140.410 , the department will pay for therapeutically appropriate, medically necessary diagnostic and treatment services for a child experiencing a severe emotional disturbance as described in 7 AAC 135.065 , including the following services: (1) individual psychotherapy; (2) group psychotherapy; (3) family psychotherapy; (4) group skill development services; (5) individual skill development services; (6) family skill development services; (7) pharmacologic management and medication administration; (8) crisis intervention; (9) intake assessment. (b) RPTC services must be provided under the direction of a physician. Psychiatric services provided by an RPTC must be provided (1) under the direct supervision of a psychiatrist licensed under AS 08.64 ; and (2) in a manner consistent with an individual plan of care that meets the requirements of 7 AAC 140.410 and is signed by the supervising psychiatrist. (c) Payment for RPTC services is limited to services provided to an individual under 21 years of age. (d) The department will not pay a residential psychiatric treatment center under this section if the department determines that noncovered services were provided. Noncovered services include (1) holding or rage therapy; (2) verbal abuse and shaming; (3) rebirthing; (4) punitive approaches to behavior management, including militaristic-style boot camp and "scared straight" programs; (5) corporal punishment, including slapping, punching, kicking, pinching, shaking, or striking with an object; and (6) therapeutic interventions not specifically directed toward the psychosocial risks and functional impairments of the child. 7 AAC 140.500. Nursing facility enrollment and conditions for payment. For a nursing facility to be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing nursing facility services, the following requirements must be met: (1) the nursing facility must (A) be enrolled with the department under 7 AAC 105.210 as an intermediate care facility or skilled nursing facility; (B) if located out of state, be enrolled in the Medicaid program in the jurisdiction where services are provided; (C) meet all federal utilization control and Medicare long-term care facility requirements under 42 C.F.R. Part 456 and 42 C.F.R. Part 483, adopted by reference in 7 AAC 160.900 ; and (D) meet all certification and licensing requirements of the jurisdiction in which the nursing facility is located; if located in this state, the nursing facility must be licensed and certified under AS 47.32 ; (2) the department has determined under 7 AAC 140.505 that the recipient's medical needs require the level of care that the nursing facility is certified to provide; (3) the department has given prior authorization to the recipient's placement in the nursing facility. 7 AAC 140.505. Authorization for admission and determination of level of care. (a) The department will authorize an individual for nursing facility services as a new admission, transfer, or continuing placement. Authorization may be given even if an individual is currently receiving services in a general acute care hospital or in an inpatient psychiatric hospital, or nonacute care services in a skilled nursing facility, an intermediate care facility, a home, or other nonacute setting. The department will determine the appropriate level of care by considering (1) the type of care required; (2) the qualifications of the person necessary to provide direct care; and (3) whether the recipient's overall condition is relatively stable or unstable. (b) To receive payment under 7 AAC 105 - 7 AAC 160 , a nursing facility, on a form provided by the department, must request (1) the authorization for admission of the recipient: (2) a level-of-care determination; and (3) a length-of-stay determination. (c) When requesting authorization or reauthorization for admission and a level-of-care determination, a provider shall provide the following information: (1) the medical reason for the stay or continued stay; (2) information supporting the level-of-care decision of the facility's utilization review committee; (3) the plan of care established for the recipient by the attending physician; (4) the recipient's diagnosis, symptoms, complaints, and any complication indicating the need for admission or continued stay; (5) a description of the functional level of the recipient; (6) written objectives; (7) an order for medications, treatments, restorative and habilitative services, therapies, diet, activities, social services, and special procedures to meet these objectives; (8) the plans for continuing care, including provision for review and necessary modification of the plan; (9) the reasons why alternative placement is not feasible or appropriate; (10) the plan for discharge. 7 AAC 140.510. Intermediate care facility services. (a) The department will pay an intermediate care facility for providing the services described in (b) and (c) of this section if those services are (1) needed to treat a stable condition; (2) ordered by and under the direction of a physician, except as provided in (c) of this section; and (3) provided to a recipient who does not require the level of care provided by a skilled nursing facility. (b) Intermediate nursing services are the observation, assessment, and treatment of a recipient with long-term illness or disability whose condition is relatively stable and where the emphasis is on maintenance rather than rehabilitation, or care for a recipient nearing recovery and discharge whose condition is relatively stable but who continues to require professional medical or nursing supervision. (c) Intermediate care may include occupational, physical, or speech-language therapy provided by an aide or orderly under the supervision of licensed nursing personnel or a licensed occupational, physical, or speech-language therapist. 7 AAC 140.515. Skilled nursing facility services. (a) The department will pay a skilled nursing facility for providing skilled nursing described in (b) of this section or structural rehabilitation services described in (c) of this section if those services are (1) needed to treat an unstable condition; (2) ordered by and under the direction of a physician; and (3) provided directly by or under supervision of qualified technical or professional personnel who are authorized by state law to provide that service and who are on the premises at the time service is rendered; technical or professional personnel include a registered nurse, a licensed practical nurse, a licensed physical therapist, a licensed physical therapy assistant, a licensed occupational therapist, a certified occupational therapy assistant, a licensed speech-language pathologist, a registered speech-language pathologist assistant, and an audiologist. (b) Skilled nursing services are the observation, assessment, and treatment of a recipient's unstable condition requiring the care of licensed nursing personnel to identify and evaluate the recipient's need for possible modification of treatment, the initiation of ordered medical procedures, or both, until the recipient's condition stabilizes. (c) Structural rehabilitation services are the following services required by physician orders and provided at least five days a week until the recipient's condition fails to show continued improvement through objective evidence: (1) ongoing assessment of structured rehabilitation needs and potentials; services must be concurrent with the management of a recipient care plan, including tests and measurements of range of motion, strength, balance, coordination, endurance, functional ability, activities of daily living, perceptual deficiencies, and speech, language, or hearing disorders; (2) therapeutic exercises or activities that, because of the type of exercises employed or the condition of the recipient, must be performed by or under the supervision of a qualified physical therapist or occupational therapist, to ensure the safety of the recipient and the effectiveness of the treatment; (3) gait evaluation and treatment; (4) range-of-motion exercises that are part of the active treatment of a specific disease that has resulted in a loss of or restriction of mobility; (5) maintenance occupational or physical therapy if specialized knowledge and judgment of a qualified occupational or physical therapist are required to design and establish a maintenance therapy program based on an initial evaluation and periodic reassessment of the recipient's needs and consistent with the recipient's capacity and tolerance; (6) ultrasound, short-wave, and microwave therapy treatments; (7) hot pack, infrared treatments, and paraffin baths in particular cases where the recipient's condition is complicated by circulatory deficiencies, areas of desensitization, open wounds, fractures, or other complications; (8) services of a communications specialist, a speech-language pathologist, or an audiologist if necessary for the restoration of function in speech or hearing. 7 AAC 140.520. Care plan counseling. (a) The department will provide care plan counseling to a recipient, or to an individual who may become a recipient, who appears to require placement in a nursing facility before that individual is admitted to the nursing facility. A care plan counselor shall provide an individual with information about alternative methods of meeting the individual's need for nursing facility care. (b) The department will prepare and submit the nursing facility level-of-care authorization form required by 7 AAC 140.525 (c) or 7 AAC 140.530 (b) for each individual who receives care plan counseling from the department. (c) The department may exempt an individual from care plan counseling in specific geographic regions of the state if the department determines care plan counseling is impractical because of the low volume of nursing facility admissions, the lack of alternative methods of meeting long-term care needs, or the inability to provide care plan counseling on a timely basis. If an individual in a geographic region is exempted from care plan counseling, the nursing facility that admits the individual must meet the requirements of 7 AAC 140.525 , 7 AAC 140.530 , or 7 AAC 140.535 , whichever is applicable to the recipient. (d) Unless the individual is exempt under (c) of this section, a general acute care hospital, inpatient psychiatric hospital, or nursing facility shall inform the department that an individual is in need of care plan counseling by following the procedure in 7 AAC 140.525 , 7 AAC 140.530 , or 7 AAC 140.535 , whichever is applicable to the recipient. 7 AAC 140.525. Transfer from hospital care to nursing facility care. (a) This section applies only to a recipient in a general acute care hospital or inpatient psychiatric hospital who appears to require placement in a nursing facility. (b) The department will consider authorizing placement in a nursing facility under this section only if (1) the nursing facility placement of the recipient is cooperatively planned by the recipient's attending physician, the medical director of the nursing facility, relevant specialists, the director of nursing of the nursing facility, and the discharge coordinator of the general acute care hospital or inpatient psychiatric hospital; (2) the discharge coordinator and the director of nursing evaluate the level-of-care needs of the recipient; and (3) the nursing facility submits a preliminary evaluation establishing the need for nursing facility placement; the primary evaluation must be made by (A) the attending physician; (B) the director of nursing; and (C) any therapist, specialist, or other professional involved in planning for the care of the recipient. (c) The preliminary evaluation must be included with the request for nursing facility level-of-care authorization on the form provided by the department and include the information required in 7 AAC 140.505 (b), unless the recipient is exempt from care plan counseling under 7 AAC 140.520 (c). (d) The preliminary evaluation and authorization form must be sent by certified mail, facsimile transmission, or secure electronic transmission, to the department on or before the date of the recipient's admission to the nursing facility. (e) After evaluating the preliminary evaluation and authorization form, the department will either concur in the placement or request that the nursing facility supply additional information to support the level-of-care placement. If, after reviewing all additional information provided, the department does not find sufficient justification for continued placement in the nursing facility, the department will advise the facility that it has no more than 10 days after the date of notification to transfer or discharge the recipient. If the department approves the placement, the department will notify the facility of the length of the certification and the date on or before which the facility's utilization review committee must review the placement. 7 AAC 140.530. Transfer from nonacute care to nursing facility care. (a) This section applies only to a recipient who (1) already receives services in a nursing facility and who appears to require placement in another nursing facility; or (2) is in the recipient's home or other nonacute care setting and who appears to require placement in a nursing facility. (b) The department will consider authorizing placement in a nursing facility under this section based upon (1) the completed request for nursing facility level-of-care authorization, on the form provided by the department, and that includes the information required in 7 AAC 140.505 (b); and (2) the nursing facility's utilization review committee's evaluation for the request for nursing facility authorization. (c) The department will evaluate the request for nursing facility level-of-care authorization and the recommendation of the nursing facility's utilization review committee and either concur in the placement or request that the utilization review committee review additional information to support the level-of-care decision. If the department does not find sufficient justification to continue placement in the nursing facility, the department will advise the facility that it has no more than 30 days after the date of notification to arrange for discharge or alternative placement of the recipient. If, at the end of the 30-day period, the recipient has not been discharged or transferred, payment to the facility will be made at the facility's intermediate care facility rate or the statewide weighted average intermediate care facility rate if the facility does not provide intermediate care. If, at the end of the 30-day period, the recipient has been recommended for discharge and the facility has not yet discharged the recipient, the department will terminate payment. 7 AAC 140.535. Continuing placement in a nursing facility. (a) The department will consider authorizing the continuing placement of a recipient in a nursing facility if the nursing facility (1) submits a request for nursing facility level-of-care authorization, on a form provided by the department, and that includes the information required in 7 AAC 140.505 (b); subsequent request forms must be submitted no less than semiannually following admission to an intermediate care facility and no less than quarterly following admission to a skilled nursing facility; (2) has determined that the level of care is appropriate based upon the recommendation of the nursing facility's utilization review committee; (3) gives the authorized department representative full access to the nursing facility's records pertaining to the recipient, including the opportunity for the department representative to personally read charts and records; (4) has included in the recipient's record a copy of all utilization review committee reports and request for nursing facility level-of-care authorization forms; (5) has written policies that state that only those persons are accepted whose needs can be met by the nursing facility directly or in cooperation with community resources or other providers of care with which the facility is affiliated or has a contract; it is the responsibility of the facility to monitor admissions carefully to ensure that the nursing facility only admits recipients that it has the capability to treat. (b) A nursing facility unable to provide appropriate care for a recipient must notify the department and assist in prompt transfer of that person to a facility that can provide the care needed. (c) If a recipient believes the level-of-care determination is incorrect, the recipient may request a hearing under 7 AAC 49 . 7 AAC 140.540. Transfer of recipients. (a) No later than seven days after a nursing facility transfers a recipient to another level of care within the same facility, the nursing facility must notify the department of the transfer by submitting a current request for a level-of-care authorization on a form provided by the department. (b) Before a nursing facility transfers a recipient to another nursing facility or hospital, the facility shall, at least 10 days before the transfer, provide a written notice (1) to the recipient; (2) if applicable, to the recipient's family or guardian; (3) to the attending physician; (4) to the division of the department responsible for payment for health care services; (5) to the division of the department responsible for senior and disabilities services, if the nursing facility is proposing the transfer; and (6) to the nursing facility, if the division of the department responsible for senior and disabilities services is proposing the transfer. (c) A recipient who receives notice of a proposed transfer under (b) of this section may request a hearing under 7 AAC 49 . (d) The department may withhold payment to a nursing facility if the facility fails to comply with this section. 7 AAC 140.545. Discharge of recipients. (a) When a nursing facility's utilization review committee or the department determines that a recipient does not, or in the future will not, require continued nursing facility placement, the nursing facility shall provide, at least 10 days before the date of discharge, a written notice of proposed discharge (1) to the recipient; (2) if applicable, to the recipient's family or guardian; (3) to the attending physician; (4) to the division of the department responsible for payment for health care services; (5) to the division of the department responsible for senior and disability services, if the nursing facility is proposing the discharge; and (6) to the nursing facility, if the division of the department responsible for senior and disability services is proposing the discharge. (b) A recipient who receives notice of a proposed discharge under (a) of this section may request a hearing under 7 AAC 49 . (c) The department may withhold payment to the facility, if the facility fails to comply with this section. 7 AAC 140.550. Third-party resources. The department will immediately notify a nursing facility of a known third-party resource or credit available to a recipient, including the amount and source. A recipient's income, and third-party resources or credits, exclusive of the allowance under 7 AAC 100.554 and 7 AAC 100.558 for personal incidental needs, must be offset as part of the recipient's cost-of-care liability against the all-inclusive rate in accordance with 7 AAC 145.670 . Third-party resources and credits that become known to the nursing facility must be reported to the department. The nursing facility is responsible for collecting those resources or credits. 7 AAC 140.555. Days chargeable. The department will pay from the day of admission to a nursing facility but not for the day of discharge, transfer, or death. Transfer includes transfer from one level of care to another level of care within a single nursing facility as well as between different nursing facilities. 7 AAC 140.560. Payment during impending decertification. If the department determines that a nursing facility is deficient in areas relating to recipient care and has initiated decertification proceedings, the department will not pay for services provided to a recipient admitted to the facility, or who becomes eligible for assistance, after the date the department has notified the nursing facility that the department has initiated decertification proceedings. If a nursing facility provides both intermediate care services and skilled nursing services, the department may implement this section independently for each level of certification. 7 AAC 140.565. Payment for nursing facility transfers. (a) If the department determines that a nursing facility is deficient in areas related to recipient care and the facility transfers a recipient to another facility at the same level-of-care certification to avoid decertification or any other enforcement penalty, the department will recover from the facility the costs of transferring that recipient to the other facility. (b) If the department determines that a recipient needs a higher or lower level of care than the facility is certified to provide, the department will pay the cost of moving the recipient to a facility certified to provide a higher or lower level of care. 7 AAC 140.570. Other payments. Payment by the department is payment in full for those services authorized under Medicaid. If the nursing facility obtains from another source any additional payment for the care provided to a recipient for services that have been paid for by Medicaid, the nursing facility shall refund or credit the additional payments to the department. 7 AAC 140.575. Recipient personal funds and personal property. (a) A recipient has the right to manage the recipient's personal funds unless the recipient has been adjudicated incapacitated or the recipient's incapacity has been established in accordance with AS 13.26.353 , or the recipient has had a full guardian appointed under AS 13.26.116 or a conservator appointed under AS 13.26.165 . A recipient or a recipient's representative may delegate holding, safeguarding, accounting, or managing responsibilities to a nursing facility. If a recipient or a recipient's representative delegates holding, safeguarding, accounting, or managing responsibilities to a nursing facility, the nursing facility shall make the account required under 42 C.F.R. 483.10(c), adopted by reference in 7 AAC 160.900 , available to the recipient. The account may be used to hold the recipient's personal funds, including the amount set aside for the recipient's personal needs allowance under 7 AAC 100.558 . Recipient personal funds may be used to purchase personal incidental items, supplies, or services not otherwise furnished by the nursing facility or covered by Medicaid. (b) If a recipient delegates holding, safeguarding, accounting, or managing responsibilities to the nursing facility under (a) of this section, the nursing facility must (1) have on file a copy of a written delegation; (2) provide a written receipt to the recipient each time the facility receives the recipient's personal funds; (3) deposit the personal funds in a bank in a separate account, apart from any other bank account or accounts of the facility; if any interest is earned on the account, the interest must be apportioned in accordance with the amount of the recipient's personal funds; (4) maintain an account record for the recipient; the account record must show in detail, with supporting verification, the amount of personal funds received or disbursed on behalf of the recipient; (5) without charge, provide to a recipient at least quarterly, an accounting of financial transactions made on the recipient's behalf; (6) notify the recipient and the department when the recipient's accumulated personal funds exceed $1,500; (7) make the recipient's personal funds available to the recipient upon request during normal banking hours; (8) require a list of purchased items, including a description and price, and a receipt, for all items purchased by any person shopping for the recipient, including facility staff, an aide, a volunteer, a department employee, and a family member; and (9) get permission from the recipient or the recipient's representative before withdrawing any amount from the recipient's personal funds. (c) Upon discharge or transfer, the nursing facility shall pay to a recipient 90 percent of the recipient's personal funds on deposit with the nursing facility in the recipient's name. No more than 30 days after discharge or transfer, the facility shall give to the recipient a final accounting of the recipient's personal funds and a check for any balance on deposit. (d) The nursing facility shall retain, for three years, receipts for expenditures from a recipient's personal funds, together with the recipient's account record. (e) Upon sale or other transfer of an ownership interest in a nursing facility or a contract to provide nursing home services in a facility, both the transferor and transferee share joint responsibility in transferring the recipient's personal funds and records in an accurate and orderly manner. (f) A nursing facility may not charge a Medicaid recipient for items or services if the facility does not charge all non-Medicaid recipients for those same items and services. Charges must be for direct, identifiable services or supplies furnished to an individual recipient. A periodic "flat" rate charge for routine items, including beverages or cigarettes, is not allowed. A nursing facility may only charge for a service after it has provided the service, and for an item after it has delivered it. Charges may not exceed actual cost to the nursing facility. (g) At a recipient's request, a nursing facility shall hold and safeguard a recipient's nonmonetary personal property. A recipient's personal property must be clearly marked with the recipient's name. The nursing facility shall keep an up-to-date record of personal property separate from the facility's inventory. If items are lost, the circumstances of disappearance shall be documented in the nursing facility's records. (h) The nursing facility may not charge a recipient for holding, safeguarding, accounting, or managing personal funds or personal property. The cost of accounting and handling must be included in the facility's cost of operation. (i) The department may withhold payment to a nursing facility if the facility fails to record properly the receipt and disposition of a recipient's personal funds or personal property. (j) In this section, (1) "delegate" means to give legal authority to a person or an entity in writing; and (2) "personal funds" means money or other liquid assets owned by a recipient that are set aside for use by or on behalf of a resident of a nursing facility. 7 AAC 140.580. Required all-inclusive services. (a) A nursing facility shall provide rehabilitative nursing care, including the services of restorative aides and nurses, as part of nursing and supportive care services. (b) If a recipient needs nonemergency, continuous heavy use of oxygen, the nursing facility shall make it available for use at all times. The nursing facility shall submit a request for authorization, on a form provided by the department, shall provide on that form a detailed description of the recipient's need for continuous heavy use of oxygen, and shall include physician orders or physician or nursing notes. Payment will be made to the nursing facility at the facility's cost for the oxygen. The amount of oxygen given to the recipient must be accurately metered and measurable to the recipient. On the billing, the nursing facility shall note the metered amount of oxygen and dates used. (c) A nursing facility is responsible for transportation planning. To determine the appropriate type of carrier, the nursing facility shall consider the recipient's condition, distance to the medical facility or provider of service, and the frequency of the trip. The least expensive mode of transportation must be used consistent with these conditions. (d) Nonemergency, in-state transportation must receive prior authorization from the department. Emergency transportation must be reported to the department as soon as possible but not later than three working days after the transportation occurred. 7 AAC 140.585. Absence from nursing facility. (a) Except as provided in (b) of this section, the department will pay for reserving a bed during a planned temporary absence of a recipient from a nursing facility if the absence is not more than 12 consecutive days and the time of departure and return of the recipient are recorded in the nursing facility's records. A planned temporary absence of not more than 12 consecutive days for which the department will pay for reserving a bed includes (1) a visit with relatives and friends; and (2) leave to participate in therapeutic or rehabilitative programs, including (A) trial visits to alternative care settings to determine if permanent placement is feasible; (B) gradually increasing lengths of visits to prepare recipients for return to their home or community; and (C) an extended absence to participate in workshop evaluation for rehabilitative programs. (b) The department will not pay for reserving a bed during a temporary absence of more than 12 consecutive days, unless the department gives prior authorization for the absence. The department will not pay for reserving a bed if the recipient has total absences in excess of 12 days during a 12-month period, unless the department gives prior authorization for the absence. The facility must submit a request in writing and receive written approval from the department before the recipient leaves the nursing facility. (c) In the recipient's plan of care, the nursing facility shall document the purpose and plan of a therapeutic or rehabilitative absence. (d) If a recipient leaves a nursing facility for hospitalization, the department will not pay to reserve the recipient's bed at the nursing facility. 7 AAC 140.590. Medicare coinsurance. (a) The department will pay, on behalf of a recipient, the coinsurance established under part A of Medicare for care rendered from the 21st through the 100th day of care in a nursing facility. The department will pay the nursing facility rate established for care in that particular facility beyond the 100th day. (b) Rejection or nonpayment by Medicare of services provided by a nursing facility because the services were custodial in nature or because the facility did not choose to participate as a Medicare provider is not, by itself, justification for the department to make full payment to a nursing facility during the period from the 1st to the 100th day of care at a nursing facility. The department will make payment to the nursing facility in accordance with the level of care appropriate to the recipient's needs as determined by the nursing facility's utilization review committee and approved by the department. 7 AAC 140.595. Definitions. In 7 AAC 140.500 - 7 AAC 140.595 , (1) "licensed nursing personnel" means those persons who are registered nurses or licensed practical nurses; (2) "utilization review committee" means the facility-based medical review team composed of private physicians and other professional persons. 7 AAC 140.600. ICF/IID enrollment and conditions for payment. (a) For an intermediate care facility for individuals with an intellectual disability or related condition (ICF/IID) to be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing intermediate care services for individuals with an intellectual or development disabilities, the following requirements must be met: (1) the ICF/IID must (A) be enrolled in accordance with 7 AAC 105.210 as an ICF/IID; (B) if located out of state, be enrolled in the Medicaid program in the jurisdiction where services are provided; (C) meet all federal standards for payment and certification requirements under 42 C.F.R. Part 442, adopted by reference in 7 AAC 160.900 ; (D) meet all certification and licensing requirements of the jurisdiction in which the ICF/IID is located; if located in this state, the ICF/IID must be certified under AS 47.32 ; (E) comply with 7 AAC 140.600 - 140.640, 7 AAC 150 , and other applicable requirements of 7 AAC 105 - 7 AAC 160 ; and (F) meet the requirements of (b) of this section; (2) the department has determined that the recipient's medical needs require the level of care provided in an ICF/IID, as determined under (c) and (d) of this section. (b) The department will authorize payment for services in an ICF/IID only if the facility (1) provides a comprehensive medical, social, and psychological evaluation of each recipient, covering physical, emotional, social, and cognitive factors of each recipient's need for care and services; the facility must complete the evaluation no more than 30 days after the date of the (A) recipient's admission to the facility; or (B) request for payment under Medicaid, if the recipient is a resident of the facility who applies while in the facility; and (2) submits annually, for each state fiscal year and on a form approved by the department, a request for ICF/IID authorization that, for (A) the first request, explains the reason for admission and provides a detailed summary of the recipient's habilitative plan of care developed as required in 7 AAC 140.610 (a); and (B) subsequent requests, provides a detailed summary of the reevaluation of the recipient as required in 7 AAC 140.610 (c). (c) In determining whether a recipient qualifies under this section for ICF/IID services, the department will base its decision on the determination of a qualified intellectual disability professional within the department that the recipient meets the functional criteria in (d) of this section, and that the recipient has at least one of the following conditions: (1) intellectual or developmental disability that meets the diagnostic criteria for code 317 or 318.0, 318.1, or 318.2, as set out in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, adopted by reference in 7 AAC 160.900 ; the recipient must have an intelligence quotient of 70 points or less as determined by an individual, standardized psychological evaluation, plus up to five points to account for any measurement error; (2) a condition that is (A) one other than mental illness, psychiatric impairment, or a serious emotional or behavioral disturbance; and (B) found to be closely related to intellectual or developmental disability because that condition results in impairment of general intellectual functioning and adaptive behavior similar to that of individuals with intellectual or developmental disabilities; the condition must be diagnosed by a licensed physician and require treatment or services similar to those required for individuals with intellectual or developmental disabilities; (3) cerebral palsy that is diagnosed by a licensed physician; however, a deficit in intellectual ability need not be present; (4) seizure disorder that is diagnosed by a licensed physician; however, a deficit in intellectual ability need not be present; (5) autism that has been diagnosed by a mental health professional clinician and that meets the diagnostic criteria for code 299.00, as set out in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, adopted by reference in 7 AAC 160.900 . (d) Each condition identified in (c) of this section must (1) have originated before the age of 22 years; (2) be likely to continue indefinitely; and (3) constitute a substantial disability to the individual's ability to function in society, (A) as measured by the Inventory for Client and Agency Planning (ICAP), adopted by reference in 7 AAC 160.900 , and as evidenced by a broad independence domain score equal to or less than the cutoff scores in the department's Table of ICAP Scores by Age, adopted by reference in 7 AAC 160.900 ; or (B) for a recipient receiving services in an ICF/11D in another state, as measured by the assessment tool authorized for use in that state. (e) No more than 120 days after the date it receives a request for ICF/IID authorization, the department will evaluate that request in accordance with (a) of this section and make a determination. In that determination, the department will concur in the placement and authorize payment, deny authorization for payment, or request that the interdisciplinary team assigned under 7 AAC 140.605 provide additional information. (f) If the department, as part of its determination under (c) of this section, finds that sufficient justification does not exist to continue a recipient's placement in a facility, the department will recommend to the facility that alternative placement be found or the recipient be discharged. The department will give the facility 30 days after the date of the determination for the facility to arrange for discharge or alternative placement of a recipient. At the end of that 30-day period, if the recipient has been recommended for discharge and the facility has not yet discharged the recipient, the department will terminate payment to the facility. (g) A facility that is denied authorization for payment may appeal under 7 AAC 105.280 . A recipient whose continued placement is denied may request a hearing under 7 AAC 49 . 7 AAC 140.605. ICF/IID interdisciplinary teams. (a) An ICF/IID shall assign a recipient an interdisciplinary team, to be directly involved in the treatment of the recipient, and to develop, implement, monitor, and evaluate the habilitative plan of care required under 7 AAC 140.610 . An interdisciplinary team must include, at a minimum, (1) the recipient; (2) the recipient's (A) family members, including parents, guardians, siblings, and others similarly involved in providing general oversight of the recipient; or (B) legal guardian, if any; (3) at least one qualified intellectual disability professional; and (4) other professionals involved in the recipient's care. (b) Each member of the interdisciplinary team shall attend meetings of the team in person or by telephone and be involved in team decisions unless the clinical record, as maintained under 7 AAC 140.610 , documents that (1) the other team members determine that participation by the recipient or other individual involved with the care of the recipient is detrimental to the recipient's well being; (2) family members refuse to participate after the provider's diligent efforts to encourage participation; or (3) weather, illness, or another circumstance beyond a member's control prohibits that member from participating. (c) If a provision of 7 AAC 140.600 - 7 AAC 140.640 requires the approval, concurrence, or recommendation of the interdisciplinary team, the interdisciplinary team may issue that approval, concurrence, or recommendation only upon the concurrence of (1) each team member under (a)(3) of this section; (2) the recipient or the recipient's representative; and (3) a majority of the team members other than the members identified in (1) and (2) of this subsection. (d) The facility shall notify all absent members of the proceedings and decisions of the interdisciplinary team meeting. 7 AAC 140.610. Records, habilitative plan of care, treatment, and reevaluation. (a) An ICF/IID shall maintain a clinical record of services provided to a recipient. The clinical record must include the evaluation required in 7 AAC 140.600 (b)(1). The clinical record must also include a written, individualized habilitative plan of care that includes (1) information identifying the recipient; (2) a list of the members of the interdisciplinary team organized under 7 AAC 140.605 ; (3) a prioritized summary of the presenting problems and needs as identified during the evaluation; (4) a description of the functional level of the recipient; (5) diagnoses, symptoms, complaints, and complications indicating the need for admission or continued stay; (6) clearly stated measurable goals or behaviorally stated objectives derived from the evaluation and designed to attain or maintain the optimal physical, intellectual, social, or vocational functioning of which the recipient is presently or potentially capable; (7) orders, as appropriate, for services that are individually designed to accomplish the stated goals and objectives, including medications, treatment, habilitation services, nutrition services, social services, therapies, experiences, activities, and any special procedures; in this paragraph, "habilitation services" has the meaning given in 7 AAC 130.319 ; (8) reasons why alternative placement is not feasible or appropriate; (9) a plan for discharge and for care following discharge to assure the maximum development of self-help and living skills; that plan must include provision for appropriate services, protective supervision, and other follow-up services in the recipient's new environment; (10) documentation that the recipient or the recipient's representative actively participated in the development of the habilitative plan of care, or if active involvement is not possible, a statement of the reasons for the lack of participation; and (11) signatures of the following individuals, indicating review and approval: (A) the recipient or the recipient's representative, unless the recipient or the recipient's representative is not willing or able to participate as described in (10) of this subsection; (B) at least one physician or qualified intellectual disability professional; (C) those participating members of the interdisciplinary team organized under 7 AAC 140.605 who have reviewed and approved the plan. (b) An ICF/IID must provide (1) a protected residential setting, individualized ongoing evaluation, planning, 24-hour supervision, and coordination and integration of health and habilitative services to help a recipient reach maximum functioning capability; and (2) in accordance with the recipient's habilitative plan of care, regular participation by the recipient in professionally developed and supervised activities, experiences, or therapies, including recreation and day programming. (c) At least once a year, the interdisciplinary team assigned under 7 AAC 140.605 shall perform a medical, social, and psychological reevaluation, including a review of the recipient's progress toward meeting the goals and objectives stated in the recipient's habilitative plan of care, the appropriateness of that plan of care, an assessment of the continuing need for institutional care, and consideration of alternate methods of care. 7 AAC 140.615. Required all-inclusive services. (a) If a recipient needs non-emergency, continuous heavy use of oxygen, the ICF/IID shall make it available for use at all times. The facility shall submit a request for authorization, on a form provided by the department, shall provide on that form a detailed description of the recipient's need for continuous heavy use of oxygen, and shall include physician orders or physician or nursing notes. Payment will be made to the ICF/IID at the facility's cost for the oxygen. The amount of oxygen given to the recipient must be accurately metered and measurable to the recipient. In the billing, the ICF/IID shall note the metered amount of oxygen and dates used. (b) An ICF/IID is responsible for transportation planning. To determine the appropriate type of carrier, the facility shall consider the recipient's condition, distance to the medical facility or provider of service, and the frequency of the trip. The least expensive mode of transportation must be used consistent with these conditions. (c) Nonemergency, in-state transportation must be given prior authorization by the department. Emergency transportation must be reported to the department as soon as possible but not later than three working days after the transportation occurred. 7 AAC 140.620. Absence from an ICF/IID. (a) Except as provided in (b) of this section, the department will pay for reserving a bed during a planned temporary absence of a recipient from an ICF/IID if (1) the absence is not more than 12 consecutive days; (2) the time of departure and return of the recipient are recorded in the facility's records; and (3) the absence is for a visit with relatives or friends. (b) The department will not pay for reserving a bed during a temporary absence of more than 12 consecutive days, unless the department gives prior authorization for the absence. The department will not pay for reserving a bed if the recipient has total absences in excess of 12 days during a 12-month period, unless the department gives prior authorization for the absence. The ICF/IID must submit a request in writing to the department for any absence in excess of 12 days and receive written approval from the department before the recipient leaves the facility. The department will authorize leaves of any duration to participate in therapeutic or rehabilitative programs that include (1) trial visits to alternative care settings to determine if permanent placement is feasible; (2) gradually increasing lengths of visits to prepare recipients for return to their home or community; and (3) extended absence to participate in workshop evaluation for rehabilitative programs. (c) In the recipient's plan of care, the ICF/IID shall document the purpose and plan of a therapeutic or rehabilitative absence. (d) A recipient temporarily absent overnight or longer from the facility on activities paid for and supervised by the facility will be considered as remaining in the facility. In this subsection, "activities" includes specific trips of an educational or training nature and recreational activities, including camping, fishing, and hiking. (e) If a recipient leaves an ICF/IID for hospitalization, the department will not pay to reserve the recipient's bed at the ICF/IID. 7 AAC 140.625. Transfer of recipients. (a) Transfer to another ICF/IID may not occur without 30 days' prior written notice to the recipient and, if appropriate, the family or guardian, and to either the department or the facility, depending on whether the department or the facility is proposing the transfer. Recipients who receive notice of a proposed transfer have the hearing rights set out in 7 AAC 49 . (b) The department may withhold payment to an ICF/IID if the facility fails to comply with this section. 7 AAC 140.630. Discharge of recipients. (a) If the interdisciplinary team assigned under 7 AAC 140.605 or the department recommends that a recipient does not, or in the future will not, require continued placement in an ICF/IID, the recipient and, where appropriate, the family or guardian, and either the department or the facility, depending on whether the department or the facility is proposing the discharge, must be given 30 days' written notice before discharge. Recipients who receive notice of a proposed discharge have the hearing rights set out in 7 AAC 49 . (b) The department may withhold payment to an ICF/IID if the facility fails to comply with this section. 7 AAC 140.635. Applicability of other sections. The provisions of 7 AAC 140.550 - 7 AAC 140.575 also apply to and ICF/IID except where they conflict with specific provisions of 7 AAC 140.600 - 7 AAC 140.640 . 7 AAC 140.640. Qualified intellectual disability professional. To be considered a qualified intellectual disability professional for purposes of 7 AAC 140.600 - 7 AAC 140.640 , an individual must meet the standard for a qualified intellectual disability professional set out in 42 C.F.R. 483.430(a), adopted by reference in 7 AAC 160.900 . 7 AAC 140.700. End-stage renal disease facility enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for outpatient end-stage renal disease services, a provider must (1) be enrolled as an end-stage renal disease services facility in accordance with 7 AAC 105.210 ; (2) meet the requirements of 42 C.F.R. Part 494 (conditions for coverage for end-stage renal disease facilities), adopted by reference in 7 AAC 160.900 ; and (3) be enrolled as a Medicare provider. (b) If a provider operates end-stage renal disease facilities at more than one site, each site must enroll separately and meet the requirements of this section. (c) On or before the last day of the sixth month after the close of its fiscal year, each end-stage renal disease facility that is enrolled in this state's Medicaid program shall submit an annual report to the department. The annual year-end report is required even if the clinic did not provide medical services to Medicaid recipients during that fiscal year. The annual year-end report must include the following: (1) the most recent uniform Medicare cost report submitted by the facility to the facility's Medicare fiscal intermediary, including (A) any supporting schedules submitted with, or in support of, the facility's Medicare cost report that were transmitted to the Medicare fiscal intermediary; (B) audited financial statements that include financial information specific to the reporting facility for the time period that matches the submitted Medicare cost report; the submission must also include any audit adjustments made by the financial statement auditors; (C) reconciliation of the audited financial statements to Worksheet A of the submitted Medicare cost report; (D) the facility's post-audit working trial balance; and (E) reconciliation of the post-audit working trial balance to Worksheet A of the Medicare cost report; and (2) appropriate Medicaid Form E-1 reporting forms, adopted by reference in 7 AAC 160.900 . (d) If an end-stage renal disease facility receives an extension for timely filing a Medicare cost report from the facility's Medicare fiscal intermediary, the facility must forward to the department, not later than 30 days after the date on the letter, a copy of the Medicare fiscal intermediary's letter that grants the extension. After receipt of the letter, the department will grant a corresponding extension for the facility's year-end report. (e) Each annual year-end report will be date-stamped upon receipt by the department. The department will acknowledge the date of receipt in a notice to the provider. Not later than 20 days after receipt of an annual year-end report, the department will review the report to determine whether the submission is complete. Once the review has been completed, (1) the department will send a notice to the facility that the annual year-end report is incomplete; (2) the department will clearly identify in the notice the deficiencies and the time not later than which the department must receive the corrected or modified annual year-end report; the department will give the facility at least seven days following receipt of the notice to submit the corrected or modified annual year-end report to the department; and (3) if a notice is not sent to the provider within the 20-day period, the department will treat the annual year-end report as complete. (f) The department may conduct audits, perform special analysis, and review the records of an end-stage renal disease facility to verify compliance with Medicare and Medicaid regulations. A facility shall provide to the department financial and all other information regarding Medicaid claims for services provided by the facility to eligible recipients and shall provide access to all facility locations and records as requested by the department. (g) If a facility fails to submit the annual year-end report, or if the department determines the report to be incomplete and not corrected or modified as required under (e) of this section, the department will withhold two percent of any payment due to the facility until the end of the fiscal quarter that the report is submitted and determined complete. The department will begin withholding two percent of the treatment payment on the 30th day following the date the complete annual report is due. (h) The department will provide notice under this section by means of electronic mail. However, if there is no electronic mail account associated with the provider's enrollment, the department will provide notice by means of United States mail. 7 AAC 140.710. End-stage renal disease facility services. The department will pay a facility that meets the requirements of 7 AAC 140.700 for services that are furnished in an end-stage renal disease facility, and that are covered under 42 C.F.R. 410.50 and 410.52, adopted by reference in 7 AAC 160.900 . The department will pay a provider for services under this section in accordance with the payment conditions established under 7 AAC 140.720 and the rate established in 7 AAC 145.607 . 7 AAC 140.720. End-stage renal disease payment conditions. (a) The department will pay an end-stage renal disease facility under 7 AAC 145.607 for the recipient's first day of treatment through the last day of the third month of treatment. (b) The department will continue to pay a facility for outpatient end-stage renal disease services beginning the fourth month of treatment only if (1) the recipient (A) is enrolled in Medicare Part B; or (B) has been determined ineligible for Medicare Part B, and the ineligibility is not related to failure to comply with any part of the Medicare enrollment process; and (2) the first claim for services beginning the fourth month of treatment is accompanied by written verification of Medicare eligibility or the reason for ineligibility. (c) If the recipient is not enrolled in Medicare Part B at the commencement of treatment, (1) the end-stage renal disease facility must ensure that a Medicare application is made by or on behalf of the recipient; and (2) the claim for the recipient's first treatment for end-stage renal disease must be accompanied by (A) a photocopy of the recipient's completed Form CMS-2728-U3, End Stage Renal Disease Medical Evidence Report - Medicare Entitlement and/or Patient Registration, signed by both the patient and the attending physician; (B) verification from the United States Social Security Administration that an application for Medicare Part B has been made by or on behalf of the recipient; or (C) a Medicare Part B enrollment denial. (d) The end-stage renal disease facility shall notify the department of each change in the recipient's Medicare status or eligibility. 7 AAC 140.800. Free-standing birth center enrollment requirements. (a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for free-standing birth center services, a facility (1) must be enrolled as a free-standing birth center under 7 AAC 105.210 ; (2) must be licensed under AS 47.32 ; (3) may not be enrolled under 7 AAC 105.210 as another type of provider; and (4) must be located in this state. (b) If a free-standing birth center operates in more than one site, each site must enroll separately and meet the requirements of this section. 7 AAC 140.810. Free-standing birth center services and payment conditions. (a) The department will pay for the use of a free-standing birth center under this section in accordance with the payment rate established in 7 AAC 145.680 . (b) The department will pay for the use of a free-standing birth center under 7 AAC 145.680 only when a delivery occurs at the facility. The department will not pay for labor-only services. (c) Newborn care is considered a component of labor and delivery services provided by a free-standing birth center and may not be billed separately. (d) For purposes of billing for free-standing birth center services, the date of service is the date of delivery. (e) Nurse midwife and direct-entry midwife services provided in a free-standing birth center are not payable to the center and must be billed separately. Chapter 145 Medicaid Payment Rates Article 1 Medicaid Payment; Conditions and Methods 7 AAC 145.005. Conditions for payment. (a) The department will pay a provider for a covered service identified in AS 47.07 and 7 AAC 105 - 7 AAC 160 only if the (1) claim is submitted by a provider who is enrolled with the department under 7 AAC 105 - 7 AAC 160 ; (2) services were rendered to an individual who was eligible under 7 AAC 100 at the time the service was rendered; and (3) the department gave prior authorization for the service if required under 7 AAC 105 - 7 AAC 160 . (b) The payment rate established by the department for a given service, less the amount of cost-sharing required under 7 AAC 105.610 , constitutes full payment from the department for that service. Except as provided in 7 AAC 110.145 , a provider may not charge a recipient or recipient's relative, friend, or representative, any amount to supplement payment by the department for services to which the recipient is entitled under 7 AAC 105 - 7 AAC 160 . (c) A provider must submit a claim to the department's contractor no more than 12 months after the date of service except as provided in this subsection. The department may extend the 12-month deadline for billing if the department determines that the provider had reason to believe that the recipient was ineligible at the time service was rendered, the recipient is subsequently determined eligible by a court, hearing authority, or the department, and the claim is filed no more than 12 months after the date the department sends notice to the recipient of the court, hearing authority, or department decision that eligibility is established. The recipient's failure to notify the provider of a court, hearing authority, or department decision is not considered good cause under 7 AAC 105.280 for failure to file a claim. (d) Except as specified in (e) of this section, when a provider furnishes a covered service to a recipient who, before receiving the service, has furnished the provider with a recipient identification card, recipient identification number, or other evidence of Medicaid eligibility, the recipient is under no obligation to pay the provider for the service other than the cost-sharing amounts required under 7 AAC 105.610 . However, a recipient is liable for the full cost of the service rendered if the recipient fails to furnish a recipient identification card, recipient identification number, or other evidence of Medicaid eligibility before receiving the service. (e) If a recipient is eligible retroactively under 7 AAC 100.072 , the provider is under no obligation to submit a claim to the department for a covered service furnished to the recipient during a month the recipient was found retroactively eligible. The recipient remains liable for the cost of the service rendered during a month of retroactive eligibility until the provider has been furnished evidence of eligibility and the provider has agreed to accept payment under (g) and (h) of this section and 7 AAC 145.020 by billing the department for the service. Payments made by a recipient to the provider before retroactive eligibility has been determined by the department must be handled in accordance with 7 AAC 105.250 . (f) The department will deny a claim for payment if the provider fails to submit the claim in the form or format required by the department for claim submission. If a payment is denied under this section, the provider may appeal under 7 AAC 105.270 . (g) By providing a service to a Medicaid recipient and billing the department for that service, a provider agrees to comply with applicable department regulations. (h) A provider may not charge (1) for any administrative cost related to participation in the Medicaid program; or (2) a higher rate for any unit of service provided to a Medicaid recipient than the provider charges others, except for an amount billed Medicare. (i) If a provider receives a payment from a recipient, relative, recipient's estate, health insurance, or other source for a service provided, and the provider intends to submit a claim to the department for the same service, the provider must report that payment and must enter it as a credit against the charge to the department. 7 AAC 145.010. Prohibition against reassignment. (a) The department will not make payment on a claim known by a provider to be covered by Medicaid if the claim has been assigned, sold, or transferred, including transfers through the use of power of attorney, to a collection agency, service bureau, or individual who advances money to a provider for the provider's accounts receivable. (b) The use of a billing agent or accounting firm that bills and receives payment in the name of the provider is permitted if payment for this service is not related on a percentage or other basis to the amount to be billed or collected. 7 AAC 145.012. Cost containment measure for inflation adjustments to Medicaid payment rates. (a) To address that appropriations for fiscal year 2020 are insufficient to cover the costs of medical assistance for all persons eligible under AS 47.07 and 7 AAC 100 , the department will implement cost containment measures that prohibit the following adjustments to Medicaid payment rates for Medicaid claims with dates of services after June 30, 2019, and before July 1, 2020: (1) inflation adjustments required under 7 AAC 145.050 (b)(3), except as noted in 7 AAC 145.050 (c)-(e); (2) inflation adjustments required under 7 AAC 145.265 (b)(9); (3) inflation adjustments required under 7 AAC 145.525 ; (4) repealed 7/1/2019; (5) inflation adjustments required under 7 AAC 150.150 , except as noted in 7 AAC 150.150 (h); (6) inflation adjustments required under 7 AAC 150.160 (j) as that subsection relates to 7 AAC 150.150 ; and (7) inflation adjustments required under 7 AAC 150.190 (g) in accordance with 7 AAC 150.190 (d)(2)(B), except as noted in 7 AAC 150.190 (g)(1). (b) In this section, "inflation adjustment" means a revision that (1) is required under a provision listed in (a)(1) - (8) of this section to an existing Medicaid payment rate; and (2) results in a new Medicaid payment rate that differs from the existing Medicaid payment rate by a percentage value or overall average net change value that is either listed under this chapter or listed in (A) the most recent annual Consumer Price Index for all Urban Consumers (CPI-U), all items, for Anchorage, Alaska published by the United States Department of Labor, Bureau of Labor Statistics, adopted by reference in 7 AAC 160.900 ; (B) the Global Insight's Healthcare Cost Review; or (C) the Medicare Economic Index as required by 42 U.S.C. 1396a(bb)(3)(A), adopted by reference in 7 AAC 160.900 . 7 AAC 145.015. Payment reduced by cost-sharing. Payment provided by the department will be reduced by the amount of cost-sharing required under 7 AAC 105.610 , and represents full payment from the department for those covered services authorized under Medicaid. A recipient may be charged only for the amount of cost-sharing specified in 7 AAC 105.610 and may not be charged for any additional difference between the amount billed and the amount received in payment from the department for those covered services provided. A recipient is responsible for payment of the cost-sharing amounts required under 7 AAC 105.610 and for payment of all services not covered under Medicaid. 7 AAC 145.020. Methodology used to establish provider payment rates. (a) Regardless of the payment methodology or payment rate adopted under 7 AAC 105 - 7 AAC 160 , and except as provided in 7 AAC 155.010 with regard to tribal health programs, the department will pay a provider for a covered service at the lowest of the (1) specific payment rate established in 7 AAC 105 - 7 AAC 160 ; (2) provider's billed charges; or (3) provider's lowest charge that is advertised, quoted, posted, billed, or discounted for any other purchaser of services for that unit of service and provided on the same date, determined in accordance with (b) of this section. (b) When determining the provider's lowest charge under (a) of this section, the department will not consider (1) a sliding fee scale established in writing that is based upon income for families and individuals with income equal to or less than 250 percent of the applicable federal poverty guidelines for this state, as adopted by reference under 7 AAC 160.900 (f); (2) any single contract that contains a discounted rate for a service or group of services and that does not exceed 20 percent of a provider's annual gross income; (3) a reduced rate for a service or group of services the provider offers to the provider's employees as part of an employee benefit package; or (4) a contract with a federal or state government agency. 7 AAC 145.025. Payment for services provided out of state. (a) Unless otherwise provided in 7 AAC 105 - 7 AAC 160 , the department will pay an out-of-state enrolled provider at the lowest of (1) the billed charges; (2) 70 percent of the in-state rate identified in 7 AAC 105 - 7 AAC 160 for the specific type of provider; or (3) the rate established by the Medicaid agency in the jurisdiction where the service was provided, if the rate information is available. (b) The department may negotiate a specific payment agreement for unique expertise, for specialized services not available in this state, or for specific services that are necessary to treat the recipient. Factors that the department will consider in making the decision to negotiate a specific payment agreement under this subsection include (1) the medical necessity for the out-of-state service; (2) whether the service is widely available out of state or available only from a limited number of out-of-state providers; (3) the professional standing of the provider within the health care services community for the unique expertise or specialized service; (4) any extreme circumstance concerning the medical needs of the patient; and (5) whether a specific payment agreement is necessary to ensure access to appropriate medical services that otherwise would not be available. (c) The specific payment agreement under (b) of this section is not available for general services offered by the provider and is limited to the specific services set out in the payment agreement. General services offered by the provider and not associated with unique expertise or the specialized services outlined in the payment agreement will be paid under (a) of this section. (d) The specific payment agreement under (b) of this section must be for a specific period of time, not to exceed two years. (e) Except as provided in this section, the department will process claims for out-of-state services in accordance with the claim process established for the applicable types of provider in this state under 7 AAC 105 - 7 AAC 160 . (f) Charges to the department for out-of-state services may not exceed the provider's usual and customary charges for the same service to the general public. (g) For state fiscal year 2020, the department will pay state fiscal year 2019 Alaska Medicaid payment rates for out of state transportation and accommodation services under 7 AAC 120.405 and 7 AAC 120.425 , with the exception of transportation services under 7 AAC 120.405 (d), emergency transportation services under 7 AAC 120.415 , and air ambulance services under 7 AAC 120.420 . Article 2 RBRVS Methodology 7 AAC 145.050. Resource-based relative value scale rate-setting methodology. (a) Except as otherwise provided in 7 AAC 105 - 7 AAC 160 for certain types of providers or services, the department will establish fees for use in payment for each type of provider and service subject to 7 AAC 105 - 7 AAC 160 using the resource-based relative value scale (RBRVS) methodology described in this section. (b) The RBRVS methodology set out in this section applies to procedures that have a Medicare nonfacility individual relative value unit (RVU) established for Medicare by CMS. Medicare nonfacility individual RVUs are adopted by reference in 7 AAC 160.900 . The RBRVS payment for these procedures consists of (1) an RVU that contains (A) a work component (RVUw) that is measured by the time and intensity of effort required to provide a service; (B) a practice expense component (RVUp) that includes costs related to the provision of services, including rent, salaries, equipment, and supplies; and (C) a malpractice expense component (RVUm) that is measured by professional liability insurance premium costs; (2) a geographic practice cost index (GPCI) that is set as an adjustment factor that modifies each RVU to reflect the cost of practice in this state; each GPCI contains (A) a work component (GPCI Work); (B) a practice expense component (GPCI PE); and (C) a malpractice expense component (GPCI MP); (3) a conversion factor (CF), that is a dollar amount used to convert new and existing CPT and HCPCS codes adopted by reference in 7 AAC 160.900 (a) into a fee amount; this conversion factor as of July 1, 2019, is $39.781; on the later date of August 1, 2019, or a 30 day notice to providers, the conversion factor will be $40.974; the CF will be adjusted annually thereafter on July 1 so that an adjustment provision results in an overall average net change for all procedures described in this subsection that equals the percent change from the previous year in the most recent annual Consumer Price Index for all Urban Consumers (CPI-U), all items, for Urban Alaska published by the United States Department of Labor, Bureau of Labor Statistics, adopted by reference in 7 AAC 160.900 . (4) repealed 7/1/2019; (c) The fee for each procedure subject to RBRVS-based payment is determined using the following calculation: X (CF). For state fiscal year 2020, starting on the later date of August 1, 2019, or after a 30 day notice to the providers, providers who do not meet the Medicaid Management Information System (MMIS) enrolled provider type, or provider specialty designations in this subsection, and who are identified as the rendering provider on the claims submitted to the MMIS will have a conversion factor (CF) of $37.792: (1) provider type 046 direct entry midwife, 050 school based services, 054 family planning clinic, or 080 independent laboratory; or (2) providers who are any provider type but have a provider specialty code in the MMIS that is 001 general practice, 008 family practice, 009 gynecology, 016 obstetrics and gynecology, 049 pediatrics, 054 obstetrics, 125 adult health, 126 nurse midwife, 127 women's health/OB-GYN, 128 family health, 129 pediatric, and 130 gerontological; in this subsection, "provider specialty" means the provider's specialty identified in the provider enrollment file as of July 1, 2019. (d) The department will pay for anesthesiology services in accordance with the following calculation: ($42.90 X the number of base units for anesthesiology services) + ($36 X the number of time units), where the number of base units is determined in accordance with the Relative Value Guide, adopted by reference in 7 AAC 160.900 , and the value of one time unit is 10 minutes. The department will not make an additional payment for a physical status modifier as set out in Current Procedural Terminology, adopted by reference in 7 AAC 160.900 . For state fiscal year 2020, starting on the later date of August 1, 2019, or after a 30 day notice to the providers, the providers who are not enrolled in the MMIS as the provider types or provider specialties identified in (c) of this section, and who are identified as the rendering provider on the claims submitted to the MMIS, will receive 95 percent of the $42.90 and $36 values referenced in this subsection. (e) Except as provided in (f) of this section, and subject to 7 AAC 145.020 , if a procedure does not have an RVU established for Medicare by CMS, and is not subject to another payment methodology or fee under this chapter, the department's payment for a covered procedure will not exceed 80 percent of billed charges for the first nine billings that reflect a charge for the service that complies with the applicable standards in 7 AAC 145.020 . Thereafter, the fee will be established based on the 90th percentile of the first 10 billings. To be paid under this subsection, a billing must reflect a charge for the procedure that complies with the applicable standards in 7 AAC 145.020 . No more than three claims from a provider, group, or pay-to-provider will be used to establish a fee under this chapter. The department will periodically review and adjust specific payment rates established under this subsection. For state fiscal year 2020, starting on the later date of August 1, 2019, or after a 30 day notice to the providers, the providers who are not enrolled in the MMIS as the provider types or provider specialties identified in (c) of this section, and who are identified as the rendering provider on the claims submitted to the MMIS, will receive 95 percent of the payment rates in this subsection. (f) The department's payment for an item or service described as an "unlisted procedure," "not otherwise classified (NOC)," or "not otherwise specified" will not exceed 50 percent of billed charges if the department agrees that the item or service cannot be billed under another code, and if the billing reflects a charge for the item or service that complies with the applicable standards in 7 AAC 145.020 . For state fiscal year 2020, starting on the later date of August 1, 2019, or after a 30 day notice to the providers, the providers who are not enrolled in the MMIS as the provider types or provider specialties identified in (c) of this section, and who are identified as the rendering provider on the claims submitted to the MMIS, will receive 95 percent of the payment rates in this subsection. (g) The department will not make an additional payment for an unusual procedural service identified as modifier -22 in the list of modifiers set out in Current Procedural Terminology, adopted by reference in 7 AAC 160.900 . (h) For providers who are not required to enroll under 7 AAC 120.200 or 7 AAC 120.300 , the department will pay for nonroutine office medical and surgical supplies in accordance with the same methodology and rates established in 7 AAC 145.420 , and 7 AAC 145.421 except that, for state fiscal year 2020, starting on the later of August 1, 2019 or after a 30 day notice to the providers, rates for providers who are not enrolled in the MMIS as the provider types or provider specialties identified in 7 AAC 145.050 (c) will be reimbursed at 95 percent of the payment rates established in 7 AAC 145.420 and 7 AAC 145.421 . (i) New, previously unpriced CPT and HCPCS codes with established RVUs will, upon adoption by reference in 7 AAC 160.900 , be priced in accordance with (c) of this section, using the conversion factor in (b)(3) of this section. (j) RVU values are updated annually on July 1. Article 3 Payment Rates; Professional Services 7 AAC 145.100. Advanced practice registered nurse services payment rates. (a) The department will pay an in-state advanced practice registered nurse, including a nurse midwife, in accordance with 7 AAC 145.020 , not to exceed 85 percent of the rate determined under 7 AAC 145.050 . (b) The department will pay an out-of-state advanced practice registered nurse the rate determined under 7 AAC 145.025 . (c) The department will pay an advanced practice registered nurse acting as a surgical assistant the lesser of the billed charges or 25 percent of the rates established for an advanced practice registered nurse under (a) of this section. The department will not pay for an advanced practice registered nurse as the primary surgeon. (d) The department will not pay separately for office medical supplies and services associated with office visits and procedures because they are included in the practice expense component of the RBRVS methodology used in 7 AAC 145.050 . The department will pay for nonroutine office medical and surgical supplies in accordance with 7 AAC 145.050 (h). (e) Repealed 5/1/2016. (f) The department will pay for laboratory services in accordance with payment methodology identified in 7 AAC 145.460 . 7 AAC 145.110. Chiropractic services payment rates. (a) The department will pay an in-state chiropractor in accordance with 7 AAC 145.020 , not to exceed 100 percent of the amount determined under 7 AAC 145.050 . (b) The department will pay an out-of-state chiropractor in accordance with 7 AAC 145.025 . 7 AAC 145.120. Dental services payment rates. (a) The department will pay a dentist for dental services provided to a recipient 21 years of age or older in accordance with 7 AAC 110.145 and the Fee Schedule: Emergent Adult Dental Services, Fee Schedule: Prosthodontic Adult Dental Services, and Fee Schedule: Enhanced Adult Dental Services, adopted by reference in 7 AAC 160.900 . (b) Except for orthodontic services, the department will pay a dentist for dental services provided to a recipient under 21 years of age in accordance with 7 AAC 110.150 and the Fee Schedule: Dental Services for Children, adopted by reference in 7 AAC 160.900 . (c) The department will pay for orthodontic services in accordance with 7 AAC 110.153 and the Fee Schedule: Dental Services for Children, adopted by reference in 7 AAC 160.900 . (d) The department will review dental payment rates at the beginning of each fiscal year and may adjust the rates to reflect changes in the United States Department of Labor consumer price index and after reviewing fee profiles from the most recent calendar year's Medicaid dental claims to determine the need for adjusting payment rates. For state fiscal year 2020, payment rates will not be adjusted by the consumer price index. (e) The department will pay for services provided by an advanced practice dental hygienist in accordance with 7 AAC 110.165 and the Fee Schedule: Advanced Practice Dental Hygienist Services, adopted by reference in 7 AAC 160.900 . 7 AAC 145.130. Direct-entry midwife services payment rates. (a) The department will pay an in-state direct-entry midwife in accordance with 7 AAC 145.020 , not to exceed 85 percent of the amount determined under 7 AAC 145.050 . (b) The department will pay an out-of-state direct-entry midwife in accordance with 7 AAC 145.025 . 7 AAC 145.140. Payment for EPSDT services. (a) Except as otherwise provided in this section, the department will pay a provider in accordance with 7 AAC 145.020 for providing initial and subsequent periodic medical screening, evaluation, diagnosis, and management of a recipient under 7 AAC 110.200 , not to exceed 100 percent of the rate determined under 7 AAC 145.050 , even if the provider rendering the service is normally paid at a different rate for non-EPSDT services. (b) Except as provided under (c) of this section, for any dental, vision, or hearing screening or for a medically necessary treatment or required service provided in response to an EPSDT screening, the department will pay a provider in accordance with the rate established in 7 AAC 105 - 7 AAC 160 for that service and for that type of provider. (c) If an EPSDT service is provided by a tribal health program, the department will pay for that service at the applicable Indian Health Service encounter rate adopted by reference in 7 AAC 160.900 . (d) If an EPSDT service is provided by a federally qualified health clinic or rural health clinic, the department will pay for that service at the rate determined under 7 AAC 145.700 . (e) If an EPSDT service is provided by a certified health provider described in 7 AAC 155.030 and employed by a tribal health program, or by a public health nurse employed by a tribal health program, the department will pay for that service in accordance with (a) of this section. (f) The department will pay the United States Internal Revenue Service optional standard mileage rate for medical purposes, adopted by reference in 7 AAC 160.900 , for use of a private vehicle driven for medical purposes as described in 7 AAC 110.210 (d)(3). 7 AAC 145.150. Family planning services payment rates. (a) The department will pay for family planning services in accordance with 7 AAC 145.020 from a provider described in 7 AAC 110.230 , not to exceed 85 percent of the amount determined under 7 AAC 145.050 . (b) The department will pay for laboratory services in accordance with the payment methodology identified in 7 AAC 145.460 . 7 AAC 145.160. Imaging services payment rates. (a) The department will pay an in-state provider of x-ray services in accordance with 7 AAC 145.020 , not to exceed 100 percent of the rate established under 7 AAC 145.050 . (b) The department will pay an out-of-state x-ray provider in accordance with 7 AAC 145.025 . 7 AAC 145.170. Nurse anesthetist payment rates. (a) The department will pay an in-state registered nurse anesthetist in accordance with 7 AAC 145.020 , not to exceed 85 percent of the rate established under 7 AAC 145.050 . (b) The department will pay an out-of-state registered nurse anesthetist in accordance with 7 AAC 145.025 . 7 AAC 145.180. Nutrition services payment rates. The department will pay an in-state provider of nutrition services in accordance with 7 AAC 145.020 , not to exceed (1) $50 for the first 30 minutes of an initial assessment; (2) $25 for each 15 minutes of an initial assessment in addition to the first 30 minutes under (1) of this section; or (3) $17.50 for each 15-minute period of service following the initial assessment. 7 AAC 145.200. Physician services payment rates. (a) Except as otherwise provided in this section, the department will pay an in-state physician in accordance with 7 AAC 145.020 , not to exceed 100 percent of the amount determined under 7 AAC 145.050 . (b) The department will pay an out-of-state physician in accordance with 7 AAC 145.025 . (c) The department will not pay separately for office medical supplies and services associated with office visits and procedures because they are included in the practice expense component of the RBRVS methodology used in 7 AAC 145.050 . The department will pay for nonroutine office medical and surgical supplies in accordance with 7 AAC 145.050 (h). (d) The department will pay for laboratory or pathology services provided by a physician for which a Medicare payment rate has been established in 42 C.F.R. 405.515, adopted by reference in 7 AAC 160.900 , in accordance with the methodology used to determine payment for laboratory services in 7 AAC 145.460 . (e) Repealed 7/1/2019. (f) The department will pay, in accordance with 7 AAC 145.020 , a supervising physician, or will pay, in accordance with 7 AAC 155.010 , a tribal health program, for the services of an in-state physician assistant, except that (1) the department will pay 85 percent of the rate identified in the fee schedule established under 7 AAC 145.050 ; (2) laboratory charges will be paid in accordance with 7 AAC 145.460 ; and (3) drugs will be paid in accordance with 7 AAC 145.410 (g). (g) The department will pay an out-of-state supervising physician for the services of an out-of-state physician assistant in accordance with 7 AAC 145.025 . 7 AAC 145.220. Physician surgical procedures payment rates. (a) The department will pay an in-state physician for surgical procedures in accordance with the physician payment rates determined under 7 AAC 145.050 , subject to the following exceptions: (1) the highest-valued procedure of multiple surgeries performed on the same recipient during the same operative session or on the same day will be paid at 100 percent of the rate determined under 7 AAC 145.050 , and each additional surgery at 50 percent of the rate determined under 7 AAC 145.050 ; (2) bilateral surgeries will be paid at the lesser of billed charges or 150 percent of the rate determined under 7 AAC 145.050 ; (3) co-surgeons will be paid for the same surgical procedure, if medically necessary, by increasing the payment rate determined under 7 AAC 145.050 by 25 percent and splitting the payment equally between the surgeons; (4) intra-operative procedures only billed using modifier -54 from the list of modifiers set out in Current Procedural Terminology, adopted by reference in 7 AAC 160.900 , will be paid at the lesser of billed charges or 80 percent of the rate determined under 7 AAC 145.050 ; (5) pre-operative services that are performed by a physician other than the surgeon, and that are billed using modifier -56 from the list of modifiers set out in Current Procedural Terminology, adopted by reference in 7 AAC 160.900 , will be paid at the lesser of the billed charges or 10 percent of the rate determined under 7 AAC 145.050 ; (6) postoperative services that are performed by a physician other than the surgeon, and that are billed using modifier -55 from the list of modifiers set out in Current Procedural Terminology, adopted by reference in 7 AAC 160.900 , will be paid at the lesser of billed charges or 10 percent of the rate determined under 7 AAC 145.050 ; (7) supplies associated with surgical procedures performed in a physician's office will be paid only when a surgical procedure is approved for payment for the same date of service in the physician's office; the department will pay the lesser of the billed charges or the rate determined under 7 AAC 145.050 (h). (b) The department will pay a physician acting as a surgical assistant the lesser of billed charges or 25 percent of the rate determined under 7 AAC 145.050 . The department will pay an advanced practice registered nurse acting as a surgical assistant the lesser of billed charges or 25 percent of the rates established for advanced practice registered nurses under 7 AAC 145.100 . (c) The department will pay a physician for the use of a physician assistant, acting as a surgical assistant, the lesser of billed charges or at the same rate paid to an advanced practice registered nurse as described in (b) of this section. (d) The department will pay an out-of state physician for surgical procedures in accordance with 7 AAC 145.025 and this section. 7 AAC 145.240. Podiatry services payment rates. (a) The department will pay an in-state podiatrist in accordance with 7 AAC 145.020 , not to exceed 100 percent of the amount determined under 7 AAC 145.050 . (b) The department will pay an out-of-state podiatrist in accordance with 7 AAC 145.025 . 7 AAC 145.250. Private-duty nursing payment rates. (a) The department will pay an in-state private-duty nurse in accordance with 7 AAC 145.020 . For state fiscal year 2020, the payment rates will be 95 percent of the payment rates listed in this subsection. The payment rates must not exceed (1) $20 per 15 minutes of service provided by a registered nurse or advanced practice registered nurse, including a nurse midwife; or (2) $18.75 per 15 minutes of service provided by a licensed practical nurse. (b) The department will pay an out-of-state private-duty nurse in accordance with 7 AAC 145.025 . 7 AAC 145.260. Psychologist services payment rates. The department will pay for psychologist services in accordance with 7 AAC 145.020 , not to exceed 100 percent of the amount determined under 7 AAC 145.050 . The department will pay for neuropsychological testing in accordance with 7 AAC 145.020 , not to exceed 150 percent of the amount determined under 7 AAC 145.050 . 7 AAC 145.265. Targeted case management payment rates. (a) Before billing the department for targeted case management services, a provider of those services shall bill the recipient's alternate resources under 7 AAC 160.200 . After it receives notification from each third party of the amount, if any, that the third party will pay, the provider of targeted case management services may seek payment from Medicaid for the remaining cost of service. (b) The department will base payment for targeted case management services on a prospective monthly encounter rate, computed with data from base year 2004, as follows: (1) using the base year's reported units of contact for the specified service categories identified by the department, the department will determine the average annual proportion of time participating grantees spent providing case management services; (2) the department will compute the annual portion of case manager salaries and benefits attributed to case management, using the base year's reported expenditures for each individual providing case management services, and then, using the proportion determined in (1) of this subsection, the department will compute the average portion of salaries and benefits attributed to case management versus other activities; (3) to the number reached in (2) of this subsection, the department will add the portion of other operating costs, including travel, supplies, telephone, and occupancy costs, attributed to case management; (4) to the number reached in (3) of this subsection, the department will add direct supervisory costs, computed by using the base year's reported expenditures for each individual who provides direct supervision to case managers, and then, using the proportion determined in (1) of this subsection, computing the portion of salaries and benefits attributed to direct supervision of case managers versus other activities; (5) to the number reached in (4) of this subsection, the department will add the average indirect administrative costs of provider organizations, computed by using the base year's reported expenditures for indirect administrative costs, and then, using the proportion determined in (1) of this subsection, computing the portion of indirect administrative costs attributed to case management versus other activities; (6) the department will divide the sum of the results reached in (2) - (5) of this subsection by the total number of statewide case managers to obtain the total annual cost per case manager; the department will determine the total number of statewide case managers by calculating the portion of direct service provider full-time equivalents dedicated to case management, using the base year's actual reported full-time equivalents and the proportion determined in (1) of this subsection; (7) the department will divide the total annual cost per case manager, as computed in (6) of this subsection, by 12 to obtain the monthly statewide average cost per case manager; (8) using the base year's average actual number of children served per case manager, the department will divide the monthly statewide average cost per case manager by the statewide average number of children served by each case manager per month; (9) the calculated rate from base-year data will be annually updated by 2.7 percent for inflation on July 1 of each year; (10) for state fiscal year 2020, the department will not apply the inflation adjustment described in (9) of this subsection. (c) A provider of targeted case management services may only bill the encounter rate once per child per month and must keep documentation to verify that practice. 7 AAC 145.270. Telehealth payment rates. (a) The department will pay in accordance with 7 AAC 145.020 for a service delivered by means of a telehealth modality by a rendering provider or a consulting provider in accordance with 7 AAC 110.620 - 7 AAC 110.639 as set out under 7 AAC 145.020 . (b) The department will pay a rendering provider or a consulting provider in the same manner as payment is made for the same service provided through in-person mode of delivery, not to exceed 100 percent of the rate established under 7 AAC 145.050 . (c) In this section, "telehealth," "rendering provider," and "consulting provider" have the meanings given in 7 AAC 110.639 . 7 AAC 145.275. Vaccine services payment rates. The department will pay for (1) a vaccine product that is covered under 7 AAC 110.750 at the lesser of the (A) billed charges; (B) Medicare Part B upper payment limit, if established; or (C) estimated acquisition cost as defined in 7 AAC 145.400 (p); and (2) administration of a vaccine product that is covered under 7 AAC 110.750 , by (A) a physician, at the rate established in 7 AAC 145.200 (a) or (b); (B) an advanced practice registered nurse, at the rate established in 7 AAC 145.100 (a) or (b); (C) a physician assistant, at the rate established in 7 AAC 145.200 (f) or (g); or (D) a pharmacist, at 85 percent of the rate established in 7 AAC 145.050 . 7 AAC 145.280. Vision examinations and services payment rates. (a) The department will pay an in-state ophthalmologist, optometrist, or optician in accordance with 7 AAC 145.020 , not to exceed 100 percent of the amount determined under 7 AAC 145.050 . (b) The department will pay for postoperative management services provided by an optometrist at 10 percent of the rate determined under (a) of this section. (c) The department will pay an out-of-state ophthalmologist, optometrist, or optician in accordance with 7 AAC 145.025 . (d) In addition to the rate paid under (a) - (c) of this section, the department will pay a provider for shipping eyeglasses and contact lenses that are dispensed by mail. Effective July 1 of each year, the department will establish the reimbursement rate for shipping at a rate equal to the United States Postal Service Priority Mail Small Flat Rate Box rate effective on July 1 of that year. 7 AAC 145.290. Long-term services and supports targeted case management. (a) For long-term services and supports targeted case management services provided under 7 AAC 128.010 , the department will pay a unit of service at the lesser of the (1) amount charged by the provider to the public; or (2) the payment rate established in the department's Chart of Long Term Services and Supports Targeted Case Management Services Rates, adopted by reference in 7 AAC 160.900 . (b) The payment rates in the Chart of Long Term Services and Supports Targeted Case Management Services Rates will be reestablished at least every four years using a modeled rate methodology as noted in the department's Rate-Setting Methodology for Personal Care Services, Community First Choice Services, Long-Term Services and Supports Targeted Case Management Services, and Waiver Services, adopted by reference in 7 AAC 160.990 , that includes components for salaries, fringe benefits, administrative/general, and case load size. (c) Each July 1 that the payment rates in the Chart of Long Term Services and Supports Targeted Case Management Services Rates are not re-established under (b) of this section, the department will adjust the payment rate for inflation using the CMS Home Health Agency Market Basket in the most recent quarterly publication of Global Insight's Healthcare Cost Review available 60 days before July 1. (d) Each July 1 that the payment rates listed in the Chart of Personal Care Services and Community First Choice Services Rates are re-established under (b) of this section or adjusted under (c) of this section, the department will further adjust the payment rates to reflect regional differences in the cost of doing business based on the designated planning regions described in Table I-1 of the Alaska Geographic Differential Study 2008, dated April 30, 2009, and adopted by reference in 7 AAC 160.900 , with a factor of 1.00 being the lowest factor applied and with the four southeast regional factors being averaged to a single weighted applicable factor of 1.09. 7 AAC 145.295. Justice-involved youth targeted case management. (a) For justice-involved youth targeted case management provided under 7 AAC 110.605 , the department will pay a unit of service at the lesser of the (1) amount charged by the provider to the public; or (2) the payment rate established in the department's Chart of Justice-Involved Youth Targeted Case Management Services Rate, adopted by reference in 7 AAC 160.900 . (b) The payment rate in the Chart of Justice-Involved Youth Targeted Case Management Services Rate will be re-established at least every four years using a modeled rate methodology that includes components for salaries, fringe benefits, and allowable indirect costs. (c) Each July 1 that the payment rate in the Chart of Justice-Involved Youth Targeted Case Management Services Rate is not re-established under (b) of this section, the department will adjust the payment rate for inflation using the CMS Home Health Agency Market Basket in the most recent quarterly publication of the S&P Global Market Intelligence Healthcare Cost Review available 60 days before July 1. Article 4 Payment Rates; Therapies and Related Services 7 AAC 145.300. Occupational therapy services payment rates. (a) The department will pay an in-state occupational therapist in accordance with 7 AAC 145.020 , not to exceed 85 percent of the rate determined under 7 AAC 145.050 . (b) The department will pay an outpatient occupational therapy program operated by a tribal health program in accordance with 7 AAC 155.010 . (c) The department will pay an out-of-state occupational therapist for services in accordance with 7 AAC 145.025 . 7 AAC 145.310. Outpatient therapy center payment rates. (a) The department will pay for outpatient therapy center services provided in state in accordance with 7 AAC 145.020 , not to exceed 85 percent of the amount determined under 7 AAC 145.050 . (b) The department will pay an out-of-state outpatient therapy center in accordance with 7 AAC 145.025 . (c) The department will pay an out-of-state outpatient therapy center in accordance with 7 AAC 145.025 for the services of an occupational therapy assistant, physical therapy assistant, or speech-language therapist assistant. 7 AAC 145.320. Physical therapy services payment rates. (a) The department will pay an in-state physical therapist in accordance with 7 AAC 145.020 , not to exceed 85 percent of the rate determined under 7 AAC 145.050 . (b) The department will pay an outpatient physical therapy program operated by a tribal health program in accordance with 7 AAC 155.010 . (c) The department will pay an out-of-state physical therapist for services in accordance with 7 AAC 145.025 . 7 AAC 145.330. Speech-language pathology services payment rates. (a) The department will pay an in-state speech-language pathologist in accordance with 7 AAC 145.020 , not to exceed 85 percent of the rate determined under 7 AAC 145.050 . (b) The department will pay an outpatient speech-language therapy program operated by a tribal health program in accordance with 7 AAC 155.010 . (c) The department will pay an out-of-state speech-language pathologist for services in accordance with 7 AAC 145.025 . 7 AAC 145.340. Hearing services payment rates. (a) Subject to the limitations in 7 AAC 115.530 , and this section, the department will pay an in-state audiologist for audiology services (1) in accordance with 7 AAC 145.020 , not to exceed 85 percent of the rate determined under 7 AAC 145.050 ; and (2) in accordance with the CPT Fee Schedule for Audiology Services table and HCPC Fee Schedule for Audiology Services table, adopted by reference in 7 AAC 160.900 ; for state fiscal year 2020, starting the later date of August 1, 2019, or after a 30 day notice to the providers, the payment rates for audiology services reimbursed under the Resource Based Relative Value Scale (RBRVS) methodology will be as described in 7 AAC 145.050 and the payment rates for audiology services not reimbursed under RBRVS will be 95 percent of the state fiscal year 2019 payment rates. (b) Subject to the limitations in 7 AAC 115.530 and this section, the department will pay an in-state hearing aid dealer for hearing aid dealer services in accordance with the HCPC Fee Schedule for Hearing Aid Dealer Services table, adopted by reference in 7 AAC 160.900 . (c) Subject to the limitations in 7 AAC 115.530 and this section, the department will pay an out-of-state audiologist or hearing aid dealer in accordance with 7 AAC 145.025 . (d) The department will pay for the rental of hearing equipment and accessories at a rate not to exceed 10 percent of the purchase price per month for a maximum of 10 months. The department will not pay for a rental beyond the purchase price of the hearing equipment. (e) Subject to the limitations in 7 AAC 115.530 and this section, the department will pay for monaural and binaural hearing aids billed at the following rates and using the following codes from the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900 : (1) code V5050 for any type of monaural hearing aid in the ear, $1,500; (2) code V5060 for any type of monaural hearing aid behind the ear, $1,500; (3) code V5130 for any type of binaural hearing aid in the ear, $3,000; (4) code V5140 for any type of binaural hearing aid behind the ear, $3,000. (f) If an item or service provided to a recipient is not included in a fee schedule described in (a)(2) or (b) of this section, the department will pay an audiologist or hearing aid dealer for that item or service at 80 percent of billed charges in this state for the first nine billings for the same item or service. Thereafter, the payment rate will be established based on the 50th percentile of the first 10 billings. The department will add a new payment rate to the fee schedule each time the department receives 10 billings for that item or service not already on the schedule. To be paid under this subsection, a billing must reflect a charge that complies with the applicable standards in 7 AAC 105.120 . (g) The department will not pay more than the following amounts for the following services: (1) manufacturer's warranty deductible fee, $300 per hearing aid; (2) postage or delivery costs from an audiologist or hearing aid dealer to a recipient, $30; payment under this paragraph includes payment for a return receipt postal fee when requested at the time of mailing, but does not include payment for postal insurance; (3) postage or delivery costs from a manufacturer to an audiologist or hearing aid dealer following the manufacturer's repair of a hearing item, $30. 7 AAC 145.350. School-based services payment rates. (a) The department will pay for school-based services in accordance with 7 AAC 145.020 , not to exceed 85 percent of the rate established under 7 AAC 145.050 . For school-based services for which a rate is not established under 7 AAC 145.050 , the department will pay for those services in accordance with the CPT Fee Schedule for School-Based Services table and HCPC Fee Schedule for School-Based Services table, adopted by reference in 7 AAC 160.900 . (b) In this section, "school-based services" has the meaning given 7 AAC 115.600 (h). Article 5 Payment Rates; Prescription Drugs and Medical Supplies; Durable Medical Equipment; Transportation; Laboratory Services 7 AAC 145.400. Covered outpatient drug payment rates and home infusion therapy drug rates. (a) In addition to complying with the requirements of 7 AAC 105.220 , and before submitting a claim for payment from the department, a pharmacy provider shall bill any third-party prescription drug plan in which the recipient is enrolled and that is in effect on the date of service. After the pharmacy provider receives notification from the third-party prescription drug plan of the amount, if any, that the third-party prescription drug plan will pay, the pharmacy provider may submit a claim for payment from the department for the remaining cost of service. The department will pay the pharmacy provider the lesser of the difference between the payment by the third-party prescription drug plan and the department-calculated allowable payment, minus any recipient cost-sharing amounts imposed under AS 47.07.042 by the department or the remaining patient liability amount, minus any recipient cost-sharing amounts imposed under AS 47.07.042 by the department. The department will consider the payment to be payment in full. (b) For a prescription of a covered outpatient drug as described in 7 AAC 120.110 (b), the department will pay the provider for reasonable and necessary postage or freight shipping, not to exceed $16, incurred in the delivery of the prescription from the dispensing pharmacy to the recipient if pharmacy services are not available in the recipient's community. If multiple prescriptions for covered outpatient drugs are shipped in a single package, the postage or freight shipping costs must be divided by the number of prescriptions for covered outpatient drugs shipped and the partial postage amount is to be billed on each prescription claim. (c) The department may establish a state maximum allowable cost for a covered outpatient drug described in 7 AAC 120.110 (b). The state maximum allowable cost will be established by reviewing pricing sources, including the wholesale acquisition cost, purchase invoices, or direct price for the covered outpatient drug as identified in the First Data Bank National Drug Data File (NDDF) Plus, taking into consideration the cost of the most frequently dispensed drugs. (d) The department will maintain on its website, or on the website of the department's designated contractor, a current listing of covered outpatient drugs and their corresponding state maximum allowable costs. (e) The payment for covered outpatient drugs described in 7 AAC 120.110 (b) is the lowest of the following: (1) the submitted covered outpatient drug cost plus the dispensing fee set under 7 AAC 145.410 ; (2) the federal upper limit established by CMS plus the dispensing fee; (3) the estimated acquisition cost of the covered outpatient drug plus the dispensing fee; (4) the state maximum allowable cost plus the dispensing fee. (f) The department will pay for a vaccine product at the rate established in 7 AAC 145.275 (1). (g) The payment for brand names of multiple-source drugs that are covered outpatient drugs described in 7 AAC 120 . 10(b) and that the prescriber specifies in accordance with 42 C.F.R. 447.512, adopted by reference, is the lowest of the following: (1) the submitted covered outpatient drug cost plus the dispensing fee set under 7 AAC 145.410 ; (2) the estimated acquisition cost of the covered outpatient drug plus the dispensing fee. (h) For a specific covered outpatient drug described in 7 AAC 120.110 (b), a provider may not submit a charge to the department in excess of the amount applicable to that drug under 7 AAC 145.020 or the provider's usual and customary charge for the covered outpatient drug. The usual and customary charge is the lowest amount a provider charges to the general public and reflects all advertised savings, discounts, special promotions, or other programs. The department will pay the lesser of the calculated allowed amount under (e) - (o) of this section less any cost-sharing amount under 7 AAC 105.610 , the charged amount submitted under 7 AAC 145.020 less any cost-sharing amount under 7 AAC 105.610 , or the provider's usual and customary charge less any cost-sharing amount under 7 AAC 105.610 . (i) For a compounded prescription that contains one or more covered outpatient drugs described in 7 AAC 120.110 (b), the department will pay the sum of the dispensing fee set under 7 AAC 145.410 and the cost of each covered outpatient drug, with the cost of each covered outpatient drug set at the lowest of the following: (1) the submitted cost for that covered outpatient drug; (2) the federal upper limit established by CMS for that covered outpatient drug; (3) the state maximum allowable cost for that covered outpatient drug; (4) the estimated acquisition cost for that covered outpatient drug. (j) A provider that dispenses covered outpatient drugs described in 7 AAC 120.110 (b) in unit doses to a recipient in a long-term care facility shall return unused covered outpatient drugs to the pharmacy, and the claim will be adjusted. (k) For covered outpatient drugs described in 7 AAC 120.110 (b) and used as home infusion therapy drugs for patients in a long-term care facility, the department will pay a provider the sum of the dispensing fee set under 7 AAC 145.410 and the cost of each covered outpatient drug, with the cost of each covered outpatient drug set at the lowest of the following: (1) the submitted cost for that covered outpatient drug; (2) the state maximum allowable cost for that covered outpatient drug; (3) the federal upper limit established by CMS for that covered outpatient drug; (4) the estimated acquisition cost for that covered outpatient drug. (l) For covered outpatient drugs described in 7 AAC 120.110 (b) and used as home infusion therapy drugs for patients outside a long-term care facility, the department will pay a provider the sum of the covered outpatient drug costs without a dispensing fee, with the cost of each covered outpatient drug set at the lowest of the following: (1) the submitted cost for that covered outpatient drug; (2) the state maximum allowable cost for that covered outpatient drug; (3) the federal upper limit established by CMS for that covered outpatient drug; (4) the estimated acquisition cost for that covered outpatient drug. (m) If a facility is a covered entity as described in 42 U.S.C. 256b (sec. 340B, Public Health Service Act) and indicates to the United States Department of Health and Human Services that it will use covered outpatient drugs purchased through the 340B drug pricing program under 42 U.S.C. 256b and 42 C.F.R. Part 10 to bill Medicaid, the facility must notify the department and may not submit a charge to Medicaid for more than the actual acquisition cost of the covered outpatient drug and a dispensing fee calculated under 7 AAC 145.410 . If a covered entity as described in 42 U.S.C. 256b notifies the United States Department of Health and Human Services, Health Resources and Services Administration, Office of Pharmacy Affairs of any changes in the entity's enrollment or participation in the program, including that the entity's pharmacy is not included under 42 U.S.C. 256b, that the entity's pharmacy is going to begin using covered outpatient drugs purchased through the 340B program to bill Medicaid, or that the pharmacy is no longer going to use covered outpatient drugs purchased through the 340B program to bill Medicaid, the entity shall also notify the department. For covered outpatient drugs from a facility indicating to the United States Department of Health and Human Services that it will use covered outpatient drugs purchased through the 340B drug pricing program to bill Medicaid, the department will pay the lesser of the following: (1) the submitted actual acquisition covered outpatient drug cost plus the dispensing fee set under 7 AAC 145.410 ; (2) the federal upper limit established by CMS plus the dispensing fee; (3) the estimated acquisition cost plus the dispensing fee; (4) the state maximum allowable cost plus the dispensing fee. (n) For purposes of (m) of this section, actual acquisition covered outpatient drug cost is the unit cost that the facility pays for a drug, after subtracting all discounts. A facility may establish written protocols for establishing or calculating the facility's actual acquisition drug cost based on a monthly, quarterly, or other average of the facility's actual acquisition drug cost. A written protocol may not include an inflation, mark-up, spread, or margin to be added to the facility's actual purchase price after subtracting all discounts. (o) If a facility purchases drugs through the Federal Supply Schedule of the United States General Services Administration or drug pricing program under 38 U.S.C. 8126, 42 U.S.C. 256b, or 42 U.S.C. 1396r-8, other than through the 340B drug pricing program under 42 U.S.C. 256b and 42 C.F.R. Part 10, the facility shall notify the department. The facility shall notify the department of any changes in participation in purchasing drugs through the Federal Supply Schedule or drug pricing program under 38 U.S.C. 8126, 42 U.S.C. 256b, or 42 U.S.C. 1396r-8. For covered outpatient drugs from a facility purchasing drugs through the Federal Supply Schedule or drug pricing program under 38 U.S.C. 8126, 42 U.S.C. 256b, or 42 U.S.C. 1396r-8 other than through the 340B drug pricing program, the department will pay the lesser of the following: (1) the submitted covered outpatient drug cost plus the dispensing fee set under 7 AAC 145.410 ; (2) the federal upper limit established by CMS plus the dispensing fee; (3) the wholesale acquisition cost of the covered outpatient drug minus 15 percent plus the dispensing fee; (4) the state maximum allowable cost plus the dispensing fee. (p) In this section, (1) "estimated acquisition cost" means the wholesale acquisition cost plus one percent; (2) "home infusion therapy" (A) means drugs that require the use of a laminar flow hood or clean room for the protection of either the product or preparing personnel; (B) includes cancer chemotherapy drugs, intravenous antibiotics, and hyperalimentation drugs; (3) "wholesale acquisition cost" means the manufacturer's list price for the drug to wholesalers or direct purchasers in the United States, not including prompt-pay or other discounts, rebates, or reductions in price, for the most recent month for which the information is available, as reported in wholesale price guides or other publications of drug pricing data. 7 AAC 145.410. Dispensing fee. (a) Except as provided under (b) of this section, and in accordance with the following, the department will pay a dispensing fee for a covered outpatient drug if the claim satisfies all coverage criteria under 7 AAC 120.110 - 7 AAC 120.140 : (1) to a non-tribal pharmacy located on the road system, $11.80 to be paid not more than once every 22 days per pharmacy per covered outpatient drug; (2) to a non-tribal pharmacy not located on the road system, $22.17 to be paid not more than once every 22 days per pharmacy per covered outpatient drug; (3) to a tribal pharmacy, $26.81 to be paid not more than once every 22 days per pharmacy per covered outpatient drug; (4) to a non-tribal or tribal mediset pharmacy, $16.58 to be paid not more than once every 14 days per pharmacy per covered outpatient drug; (5) to an out-of-state pharmacy, $10.76 to be paid not more than once every 22 days per pharmacy per covered outpatient drug; (6) the dispensing fee for a compounded covered outpatient drug is the applicable fee listed in (1) - (5) of this subsection; (7) a claim submitted by a provider for the same covered outpatient drug for which a dispensing fee was paid within the last 14 or 22 days, as applicable under (1) - (6) of this subsection, will be paid without the dispensing fee listed in (1) - (6) of this subsection. (b) The department will pay, under (a), (c), or (g) of this section, the lesser of the assigned dispensing fee or the submitted dispensing fee. (c) Upon request by the department, a pharmacy shall produce business records and invoice information relevant to the cost of drugs and the cost of dispensing. If a pharmacy does not provide cost of drugs or dispensing fee data as requested by the department, the department may assign that pharmacy the dispensing fee of $3.45 and sanction the pharmacy as provided under 7 AAC 105.400 - 7 AAC 105.490 . (d) A pharmacy may not refuse to fill an interim prescription for a covered outpatient drug occurring before the end of the 14 or 22 days as applicable under (a)(1) - (5) of this section because an additional dispensing fee will not be paid. (e) In addition to a dispensing fee under (a) - (c) of this section for a tobacco cessation covered outpatient drug, the department will pay for tobacco cessation medication therapy management that meets the requirements of 7 AAC 120.110 (c) at the rate of $16, not more than once every 30 days. (f) The department will pay for the administration of a vaccine product covered under 7 AAC 110.750 at the rate established in 7 AAC 145.275 (2). (g) A claim for a covered outpatient drug dispensed by a dispensing provider to a recipient for outpatient use will be reimbursed in accordance with 7 AAC 145.400 with no dispensing fee. A covered outpatient drug administered to an outpatient recipient by a physician, advanced practice registered nurse, or physician assistant, and billed using a covered code under the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900 , will be reimbursed at the estimated acquisition cost defined in 7 AAC 145.400 (p) for the amount administered with no dispensing fee. For state fiscal year 2020, starting on the later of August 1, 2019 or after a 30 day notice to the providers, a covered outpatient drug administered to an outpatient recipient by a physician, advanced practice registered nurse, or physician assistant that is not enrolled in the Medicaid Management Information System (MMIS) as a provider type or provider specialty identified in 7 AAC 145.050 (c), and who is identified as the rendering provider on the claim submitted to the MMIS billed using a covered CPT or HCPCS code will be reimbursed at 95 percent of the estimated acquisition cost defined in 7 AAC 145.400 (p) with no dispensing fee. (h) In this section, (1) "congregate living home" includes a long-term care facility, an assisted living home licensed under AS 47.32 , a residential psychiatric treatment center, or other group home; (2) "mediset" means a quantity or unit dose of a prescription covered outpatient drug that the provider repackages into single-dose packing to help a recipient adhere to difficult dosing regimens; (3) "mediset pharmacy" means a pharmacy dispensing 75 percent or more of the total annual Medicaid prescriptions for covered outpatient drugs in prescriber-ordered medisets or unit doses to a recipient living in a congregate living home, a recipient of home and community-based waiver services, a recipient eligible for Medicaid under a category set out in 7 AAC 100.002 (b) or (d) who is blind or disabled, a recipient who is an adult experiencing a serious mental illness as described in 7 AAC 135.055 , or a recipient who is a child experiencing a severe emotional disturbance as described in 7 AAC 135.065 ; (4) "non-tribal pharmacy" means a pharmacy that does not meet the definition for "tribal health program" under 7 AAC 160.990 (b); (5) "out-of-state pharmacy" means a pharmacy that is physically located in a state other than this state; (6) "pharmacy located on the road system" means a pharmacy that is located in this state and is connected to Anchorage by road; (7) "pharmacy not located on the road system" means a pharmacy that is located in this state and is not connected to Anchorage by road; (8) "tribal pharmacy" means a pharmacy that meets the definition for "tribal health program" under 7 AAC 160.990 (b); (9) "unit dose" means a quantity of a covered outpatient drug that the provider repackages into single dosage packing. 7 AAC 145.420. Durable medical equipment, supplies, prosthetics, orthotics, and respiratory therapy payment rates. (a) Payment by the department to a provider enrolled under 7 AAC 105.210 as a durable medical equipment provider will be made in accordance with this section. (b) A provider enrolled under 7 AAC 105.210 as a durable medical equipment provider providing durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200 (a)(2) to eligible recipients may submit, as follows, claims covered in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900 , for which a rate or rate methodology has been established by CMS or the department or for covered codes with rate-setting methodologies set out in (c) - (e) of this section: (1) payment rates set by the department for items and services provided by enrolled providers to recipients physically located in this state will be based on 100 percent of the current quarter's Medicare DMEPOS Fee Schedule established by CMS for these items and services in this state; (2) payment rates set by the department for items and services provided to recipients when the recipient is physically located outside of this state will be based on 100 percent of the current quarter's Medicare DMEPOS Fee Schedule established by CMS for these items and services in the state where the item or service was provided; (3) payment rates set by the department for items and services not established on the current quarter's Medicare DMEPOS Fee Schedule will be based on the methodology set out in (c) - (f) of this section. (c) Payment rates for durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200 (a)(2) for covered non-miscellaneous codes that are from the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900 , but for which CMS has not issued a rate on the current quarter's Medicare DMEPOS Fee Schedule as described in (b) of this section or for which the department has not established a rate and published the rate on the Alaska Medicaid DMEPOS Fee Schedules, Tables I-5 through I-9, adopted by reference in 7 AAC 160.900 , or Alaska Medicaid DMEPOS Interim Fee Schedule, will be based on the submitted unaltered final purchase invoice price plus 35 percent, as follows, for claims submitted on or after June 2, 2019 and before the date the rate is established, until a rate is set by CMS or the department: (1) if the median unaltered final purchase invoice price of the non-miscellaneous HCPCS item for the first 10 claims is less than $5,000, the final rate will be set at (A) the median submitted unaltered final purchase invoice price of the first 10 claims plus 35 percent if the first 10 claims were paid to at least two different enrolled providers; or (B) the median submitted unaltered final purchase invoice price of the number of claims paid, plus 35 percent after 15 claims are paid but have not been paid to at least two different enrolled providers; (2) if the median unaltered final purchase invoice price of the non-miscellaneous HCPCS item for the first 10 claims is $5,000 or more, the final rate will be set at (A) the median submitted unaltered final purchase invoice price plus 30 percent if the first 10 claims were paid to at least two different enrolled providers; or (B) the median submitted unaltered final purchase invoice price of the number of claims paid, plus 30 percent after 15 claims are paid but have not been paid to at least two different enrolled providers; (3) when applicable, the rental rates for a covered item non-priced, non-miscellaneous HCPCS code for which CMS or the department has not issued a permanent rate will be 10 percent of the rate set out in (1) of this subsection; (4) all claims paid under this subsection must be submitted with an unaltered final purchase invoice, free of alteration described in (o) of this section; claims submitted without an unaltered final purchase invoice or with anything other than an unaltered final purchase invoice will be denied. (d) Payment rates for covered items submitted using a miscellaneous HCPCS code as defined in 7 AAC 120.399 for which CMS or the department has not issued a rate as described in (b) of this section will be paid, as follows, at the unaltered final purchase invoice price plus 20 percent: (1) the department will not set a generic rate for the miscellaneous HCPCS code, but the department may set a rate based on a national drug code product identifier or other product identifier and may require the unique identifier to be submitted on claims to facilitate payment; (2) claims submitted for miscellaneous HCPCS codes under this section for which a product-specific rate has not been established and published on the Alaska Medicaid DMEPOS Fee Schedules, Tables I-5 through I-9, adopted by reference in 7 AAC 160.900 , or Alaska Medicaid DMEPOS Interim Fee Schedule must be submitted with an unaltered final purchase invoice, free of alteration described in (o) of this section; claims submitted without an unaltered final purchase invoice or with anything other than an unaltered final purchase invoice will be denied; (3) when applicable, for a covered item defined under a miscellaneous code for which CMS or the department has not issued a price, the rental rate will be 10 percent of the purchase invoice price plus 20 percent. (e) Rates established by the department under this section for a covered code for which CMS has not issued a rate may be published on the department's Alaska Medicaid DMEPOS Interim Fee Schedule. (f) A provider enrolled under 7 AAC 105.210 as a durable medical equipment provider may submit claims for labor and repair parts for damaged durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, and related items and services under 7 AAC 120.200 (a)(2) with the following limitations: (1) the department will not pay more than the corresponding labor rate listed on the Alaska Medicaid DMEPOS Fee Schedule, Tables I-5 through I-9, adopted by reference in 7 AAC 160.900 , for which CMS has issued a price for each 15 minutes of labor costs; (2) the billing for a repair part must reflect a charge that complies with the applicable standards in 7 AAC 145.020 and this section; (3) labor and repair parts for the item must be documented and the documentation must be submitted with each claim; documentation must include (A) a statement signed by the recipient or the recipient's authorized representative that describes the cause for and nature of the repair; (B) a description of the item being repaired and its serial number, if available; (C) the beginning and end dates of warranty coverage, if available; (D) documentation for labor charges that includes the amount of time spent on the repair, rounded up to the nearest quarter hour, and the hourly rate charged for the repair; and (E) an itemized list of parts used in the repair and associated costs; (4) a provider may not submit a claim for labor and repair parts if the item is covered under a manufacturer's or supplier's warranty, or if the labor or parts are necessary to repair an item that needs repair because of a manufacturer's defect; (5) a provider may not submit a claim for labor and repair parts for a rented item; the provider shall ensure that a rented item functions as intended after the provider repairs or replaces the item. (g) A provider enrolled under 7 AAC 105.210 as a durable medical equipment provider may submit claims for the following incontinence supplies up to the allowed quantities listed on the Alaska Medicaid DMEPOS Fee Schedule, Tables I-5 through I-9, adopted by reference in 7 AAC 160.900 , except that if a service authorization has been approved to exceed the allowed quantities based on medical necessity, payment will be determined on those supplies based on the Alaska Medicaid DMEPOS Fee Schedule, Tables I-5 through I-9, adopted by reference in 7 AAC 160.900 : (1) garments; (2) liners; (3) underpads; (4) nonsterile gloves; (5) diaper wipes; (6) disposable washcloths. (h) For a rental period that is 30 days or more, the department will pay for rented durable medical equipment at the lesser of a monthly rental rate of 10 percent of the allowed purchase rate under this section or the billed rental charge, except (1) codes that are from the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900 , that are defined as rental codes or with a specific rental rate listed on the Alaska Medicaid DMEPOS Fee Schedule, Tables I-5 through I-9, adopted by reference in 7 AAC 160.900 , may pay at the rental price listed on the Alaska Medicaid DMEPOS Fee Schedule or Alaska Medicaid DMEPOS Interim Fee Schedule: (2) capped rental items or services may be paid at the rental rate listed on the Alaska Medicaid DMEPOS Fee Schedule, Tables I-5 through I-9, adopted by reference in 7 AAC 160.900 , or on the Alaska Medicaid DMEPOS Interim Fee Schedule up to the lesser of the purchase price of the item or 13 months' worth of continuous rental. (i) For a rental period that is less than 30 days, the department will pay for rented durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200 (a)(2) at a monthly rental rate of 150 percent of the monthly fee in (h) of this section, divided by the number of days in the month, times the number of days in the rental period. Payment may not exceed the monthly rate. Codes that are from the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900 , that are defined as daily rental codes or with a specific daily rate identified on the Alaska Medicaid DMEPOS Fee Schedule, Tables I-5 through I-9, adopted by reference in 7 AAC 160.900 , will pay at the lesser of the rental price listed on the Alaska Medicaid DMEPOS Fee Schedule, the Alaska Medicaid DMEPOS Interim Fee Schedule, or the billed rental rate. (j) A provider enrolled under 7 AAC 105.210 as a durable medical equipment provider may submit claims and payment may be authorized at a rate higher than the state-based rate published on the Alaska Medicaid DMEPOS Fee Schedule, Tables I-5 through I-9, adopted by reference in 7 AAC 160.900 , for a more costly, medically necessary item of durable medical equipment, medical supply, prefabricated off-the-shelf orthotic, or related item or service under 7 AAC 120.200 (a)(2) if the recipient's medical condition substantiates the need, and documentation is submitted with the claim that demonstrates, as follows, that a less expensive product is not available to meet the medical needs of the recipient: (1) the provider may request a higher reimbursement rate by submitting the alternate reimbursement rate request form, available on the department website, with the claim and the required documentation with the claim; (2) an approved request will be reimbursed at the actual acquisition cost, as substantiated by a submitted final, unaltered invoice, free of alteration described in (o) of this section, plus (A) 35 percent for items with an actual acquisition cost below $5,000; or (B) 30 percent for items with an actual acquisition cost at or above $5,000; (3) enteral nutrition products assigned a "B" code under the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900 , and incontinence supplies assigned a "T" code are not eligible for reimbursement rates higher than those published on the Alaska Medicaid DMEPOS Fee Schedule, Tables I-5 through I-9, or the Alaska Medicaid DMEPOS Interim Fee Schedule. (k) Subject to the applicable provisions of 7 AAC 120.200 - 7 AAC 120.399 , a provider enrolled under 7 AAC 105.210 as a durable medical equipment provider may request payment for the reasonable direct costs of delivery or shipping, as follows: (1) from the manufacturer to the provider for customized or optimally configured durable medical equipment repair and replacement parts that are specialized or unique to a recipient's equipment or service and for which the final unaltered purchase invoice price exceeds $250; the shipping method used must be the most cost-effective method available; the unaltered final purchase invoice, free of alterations described in (o) of this section, must include the purchase invoice for the replacement items or repair and must include shipping costs; if the unaltered final purchase invoice is free of alterations described in (o) of this section but contains one or more items in addition to the repair or replacement part, the department will pay for the shipping cost attributed to the repair or replacement part, as calculated by dividing the shipping cost on the unaltered final purchase invoice by the number of items purchased and multiplying by the number of repair or replacement parts specific to the recipient's need; expedited, next day, rush, or delivery charges resulting from the use of a shipping method other than the most cost-effective method available will not be covered; (2) from the dispensing provider to the recipient when the following conditions apply: (A) the recipient resides outside the municipality where the business of the enrolled dispensing provider is located; (B) the item or service is unavailable from a provider enrolled under 7 AAC 105.210 in the municipality where the recipient resides; (C) the submitted claim and supporting documents include the (i) recipient's name; (ii) address to where the item was delivered; (iii) itemized list of the products included in the shipment or delivery, to include each product name, each product identifier, the quantity, and the serial number, when applicable; (iv) shipment and delivery date; (v) recipient's signature with the date of receipt; and (vi) total shipping and delivery charges minus all discounts, substantiated by a paid shipping invoice reflecting the actual payment; (3) from the recipient to the dispensing provider for the repair of recipient-owned equipment when the following conditions apply: (A) the recipient resides outside the municipality where the business of the enrolled dispensing provider is located; (B) the item or service is unavailable from a provider enrolled under this section in the municipality where the recipient resides; (C) the submitted claim and supporting documents include the (i) address to where the item was delivered; (ii) itemized list of the products included in the shipment or delivery, to include each product name, each product identifier, the quantity, and the serial number, when applicable; (iii) shipment and delivery date; (iv) recipient's signature with the date of receipt; and (v) total shipping and delivery charges minus all discounts, substantiated by a paid shipping invoice reflecting the actual payment; (4) shipping costs that qualify for coverage under this section due to the recipient traveling within or outside of this state; those costs are eligible for coverage only if the recipient is traveling for medical, educational, or vocational reasons; documentation from the prescribing physician supporting the recipient's reason for travel and including the estimated duration of travel must be submitted with the claim; shipping costs related to recreational travel are not covered. (l) Used or refurbished durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200 (a)(2) will be reimbursed at not more than 75 percent of the allowed rate for the specific item as described in (b) - (e) of this section. (m) Enteral nutrition products assigned a "B" code under the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900 , and incontinence supplies assigned a "T" code must be billed with the respective specific manufacturer product code dispensed and the correct corresponding HCPCS code and modifier as set out on the Alaska Medicaid DMEPOS Fee Schedule, Tables I-5 through I-9, adopted by reference in 7 AAC 160.900 , to be eligible for payment. Enteral product and incontinence supply reimbursement will be consistent with this section and are not eligible for higher allowable adjustment requests. (n) Providers may use the department's price research form to request formal research of a state-based specific price established by the department that has not been established by CMS using the Alaska Medicaid DMEPOS Price Research Form. (o) An unaltered final purchase invoice is considered altered if (1) information on the original invoice is removed, erased, redacted, omitted, or otherwise modified so that the copy submitted to the department is anything other than an exact copy of the original invoice received by the enrolled provider from the provider's supplier; legible markings made by an enrolled provider on the original invoice as part of the enrolled provider's normal business practices will not result in the department viewing an invoice as altered if the markings (A) do not remove, erase, redact, omit, or otherwise modify the invoice in a way that results in any of the information on the original invoice becoming illegible; and (B) appear on both the original invoice and the copy submitted to the department; or (2) the invoice shows a price other than the final price paid by the enrolled provider. (p) The Alaska Medicaid DMEPOS Fee Schedule, Tables I-5 through I-9, adopted by reference in 7 AAC 160.900 , will be available quarterly in accordance with published CMS Medicare DMEPOS fee schedules. (q) In this section, (1) "out-of-state" means that the provider is physically located in a state other than this state; (2) "in-state" means that the provider is physically located in this state.