7 Alaska Admin. Code § 120.200

Current through September 25, 2024

Section 7 AAC 120.200 - Enrollment; general provisions; covered items and services

(a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing durable medical equipment, medical supplies, and related items and services, a provider must

(1) have and maintain a valid business license issued under AS 43.70 and 12 AAC 12;

(2) be enrolled under 7 AAC 105.210 as a durable medical equipment provider, if the provider provides

(A) durable medical equipment;

(B) medical supplies;

(C) respiratory therapy assessment visits;

(D) home infusion therapy services; or

(E) prefabricated off-the-shelf orthotics;

(3) provide to the department evidence at enrollment, and at any other time upon request, that the provider is enrolled as a Medicare provider for durable medical equipment, supplies, and related items and services, and Medicare enrollment is maintained concurrent with Medicaid enrollment;

(4) comply, throughout enrollment, with federal certification standards found in 42 C.F.R. 424.57(c), adopted by reference in 7 AAC 160.900(b); and

(5) notify the department in writing not later than 30 days after the provider has a change in status of any of the requirements of this subsection; the department may sanction or disenroll under 7 AAC 105.400 - 7 AAC 105.490 a provider for failing to continuously meet the requirements of enrollment under this section.

(b) 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 medically necessary durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under (a)(2) of this section that the provider furnished to a recipient, if

(1) the item or service is

(A) prescribed by a physician, physician assistant, or advanced practice registered nurse who is enrolled under 7 AAC 105.210 and acting within the scope of that person's license;

(B) appropriate for use in the recipient's home, school, or community;

(C) not provided by, or under arrangements made by, a home health agency; and

(D) dispensed or provided under a valid prescription order from an individual under (A) of this paragraph; if a current piece of durable medical equipment needs to be repaired, each of the following must be met:

(i) all applicable warranties are expired;

(ii) the cost of the repair is less than 50 percent of the cost of a new piece of durable medical equipment, and the provider has submitted supporting documentation;

(iii) the repair has a warranty for a minimum of 30 days;

(iv) repair parts are dispensed or provided under a valid prescription order from an individual under (A) of this paragraph;

(2) the provider furnishes orientation and training to the recipient regarding the proper use of the item, and includes proof of compliance with this paragraph in its records; the provider shall submit this proof to the department upon request; and

(3) service authorization, if required under 7 AAC 120.210, is obtained from the department.

(c) 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 continuous oxygen used by a recipient in a skilled nursing facility or intermediate care facility if the skilled nursing facility or intermediate care facility has not been authorized to provide continuous oxygen under 7 AAC 140.580.

(d) 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 purchase or rental of durable medical equipment for a recipient in a skilled nursing facility or intermediate care facility if the purchase or rental is medically necessary for the recipient's preparation for discharge or for the actual discharge to home. A rental or purchase must be arranged not earlier than 30 days before the scheduled discharge and will be authorized only if the equipment is not provided by the skilled nursing facility or intermediate care facility. The department may pay for trial use of rental equipment necessary for preparing a recipient for discharge.

(e) 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 home infusion therapy services if the services are

(1) ordered by a physician, a physician assistant, or an advanced practice registered nurse;

(2) reviewed at least every 60 days by the physician, physician assistant, or advanced practice registered nurse to determine the ongoing medical need for the service; and

(3) appropriate for use in the recipient's home, school, or community.

(f) If a home infiision therapy provider is also providing skilled nursing visits ordered by the physician, physician assistant, or advanced practice registered nurse under (e) of this section, those skilled nursing visits for home infusion therapy must be provided in the recipient's home, except that the department will pay a home infusion therapy provider

(1) for one skilled nursing visit for catheter insertion and recipient instruction at

(A) a hospital on the day of discharge from the hospital;

(B) a hospital one day before the day of discharge from the hospital; or

(C) one of the following on the day of surgery:

(i) a hospital-based infusion clinic;

(ii) an ambulatory surgical center;

(2) for not more than one skilled nursing visit a day, if the total cumulative time of the visit, including multiple trips, is two hours or less; if the total cumulative time exceeds two hours in the same day, each additional hour is paid separately; or

(3) a per diem amount, if

(A) the skilled nursing visit is provided on the same day the recipient receives infusion therapy services at a hospital-based infusion clinic or an ambulatory surgical center; and

(B) a physician, physician assistant, or advanced practice registered nurse has ordered additional infusion therapy services to continue in the home.

(g) 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 medically necessary medical supplies or respiratory therapy assessment visits furnished to a recipient who is receiving hospice care services, if the supplies or assessment visits are

(1) ordered by a physician as part of a written hospice plan of care under 7 AAC 140.275 and the physician reviews the recipient's continuing medical need for the supplies or visits; and

(2) appropriate for use in the recipient's home, school, or community.

(h) 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 dispensing the following covered items described by a national drug code (NDC) listed on the Alaska Medicaid DMEPOS Fee Schedule, Tables 1-5 through 1-9, adopted by reference in 7 AAC 160.900, up to the maximum allowable quantities and amounts described on that fee schedule if the item is medically necessary due to a medical condition resulting in bladder or bowel incontinence:

Click here to view image

(1) skin sealant;

(2) skin protectant;

(3) skin moisturizer;

(4) skin ointment;

(5) skin cleanser;

(6) skin sanitizer.

(i) A provider enrolled under 7 AAC 105.210 as a durable medical equipment provider may request payment for the reasonable and necessary direct costs of delivery or shipping of durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or home infusion therapy pharmaceutical products incurred by the dispensing provider when using the most cost-effective means; to be eligible for payment, the following conditions must apply:

(1) the recipient resides outside the municipality where the business of the enrolled dispensing provider is located;

(2) the item or service is unavailable from a provider enrolled under this section in the municipality where the recipient resides;

(3) if for shipping a home infusion pharmaceutical product, the cost of the shipping by means of the most cost-effective method exceeds 40 percent of the sum of the per diem rate for the number of days represented in the shipment;

(4) the item shipping from the manufacturer to the provider is durable medical equipment or replacement parts that are specialized or unique to a recipient's equipment and for which the final unaltered purchase invoice price exceeds $250.

(j) When the shipping cost submitted to the department by the provider under (i) of this section exceeds $50, the payment request supporting documents must include

(1) the recipient's name;

(2) the address to which the item was delivered;

(3) an itemized list of the products included in the shipment or delivery, to include the product name, the product identifier, the quantity, and the serial number, when applicable;

(4) the shipment and delivery date;

(5) the recipient's signature with the date of receipt; and

(6) the total charges minus all discounts, substantiated by a paid shipping invoice reflecting the actual payment.

(k) The department will not pay separately for the costs of administrative expenses. The following costs are considered administrative expenses and are included in the payment for the durable medical equipment, medical supplies, and prefabricated off-the-shelf orthotics:

(1) telephone responses to questions;

(2) mileage;

(3) travel expenses;

(4) travel time;

(5) setting up an item;

(6) installation;

(7) orientation and training regarding the proper use of the item;

(8) preparation and maintenance of necessary records required under 7 AAC 105.230 and 7 AAC 120.210.

(l) A prescribing provider under (b)(1)(A) of this section shall review the continued medical necessity of durable medical equipment or supplies billed to Medicaid at least annually. The department may require more frequent reviews based on the nature of the item prescribed. A durable medical equipment provider enrolled under 7 AAC 105.210 who repairs a durable medical equipment product may only request payment if the product is still medically necessary. The department may seek recovery under 7 AAC 105.260 of payment for services or items determined to be medically unnecessary and impose sanctions under 7 AAC 105.400 - 7 AAC 105.490.

(m) A provider of durable medical equipment, medical supplies, and prefabricated off-the-shelf orthotics shall

(1) document and maintain record of a recipient's request for a refill, including the quantity of items that the recipient

(A) needs and requests; and

(B) possesses;

(2) supply not more than what the recipient needs for a 30-day period;

(3) accept returns from a recipient of a substandard item; for purposes of this paragraph, "substandard item" means an item that does not function in a manner that meets the prescribed need or specification;

(4) upon request, provide proof in the form of copies of letters, logs, or signed notices, that it has provided recipients with warranty information for Medicaid-covered items;

(5) maintain proof of receipt for items supplied to recipients consistent with 7 AAC 105.230; the provider shall submit the proof of receipt to the department upon request; and

(6) ensure that each recipient is eligible to receive the product.

(n) The department will only pay for medically necessary medical supplies for up to a 30-day supply within each 22-day period. The department may seek recovery under 7 AAC 105.260 of payment for services or items determined to be medically unnecessary and impose sanctions under 7 AAC 105.400 - 7 AAC 105.490.

(o) The department may enter into a contract under AS 36.30, a grant, or other arrangement permitted by law with a provider authorizing that provider to

(1) provide durable medical equipment, medical supplies, or prefabricated off-the-shelf orthotics; or

(2) serve a specific geographic region and provide incontinence supplies, including

(A) garments;

(B) liners;

(C) underpads;

(D) nonsterile gloves;

(E) diaper wipes; and

(F) disposable washcloths.

(p) A provider enrolled under 7 AAC 105.210 as a durable medical equipment provider may request payment and the department may pay for disposable incontinence products, including diapers, liners, underpads, reusable protective underpads, wipes, and washcloths for recipients three years of age or older if

(1) the items meet national quality standards as defined by the National Association for Continence (NAFC);

(2) the items are medically necessary for a medical condition resulting in bladder or bowel incontinence;

(3) the recipient has not responded to, would not benefit from, or has failed bowel or bladder training;

(4) the quantities prescribed do not exceed those established on the Alaska Medicaid DMEPOS Fee Schedule, Tables 1-5 through 1-9, adopted by reference in 7 AAC 160.900, except that subject to a service authorization required under 7 AAC 120.210, a provider may request and the department may pay for medically necessary incontinence supplies in quantities exceeding those on the Alaska Medicaid DMEPOS Fee Schedule, Tables 1-5 through 1-9, adopted by reference in 7 AAC 160.900, if a clinical assessment of need and plan attested to by the prescriber is submitted by the servicing provider; and

(5) the items are prescribed on a form that includes the items required by (t) of this section, and documentation of clinical assessment and medical necessity, certified at least annually by a physician, physician assistant, or advanced practice registered nurse who is enrolled under 7 AAC 105.210 and is acting within the scope of that person's license.

(q) In addition to meeting the requirements in 7 AAC 105.230, a recipient's medical record must contain documentation to substantiate the answers on the incontinence certificate of medical necessity. A copy of the signed incontinence certificate of medical necessity must be maintained in the recipient's medical record.

(r) A provider enrolled under 7 AAC 105.210 as a durable medical equipment provider may not make unsolicited contact with a recipient of medical assistance under 7 AAC 105 - 7 AAC 160 for the purpose of marketing the provider's products or services.

(s) The department will only pay a claim for durable medical equipment, medical supplies, or related items and services under (a)(2) of this section if the prescribing physician, physician assistant, or advanced practice registered nurse provides a face-to-face examination of the recipient not more than six months before the beginning of services as defined in 42 C.F.R. 440.70 and 42 C.F.R. 410.38. The face-to-face examination must be related to the primary reason that the recipient requires the durable medical equipment, medical supplies, or related items and services.

(t) A prescription order for durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, and related items and services must contain the

(1) recipient's name and date of birth;

(2) item or service being prescribed;

(3) diagnosis;

(4) international classification of disease code;

(5) quantity of the item or service being prescribed;

(6) directions or instructions for proper use of the item or service, including the frequency of use when applicable;

(7) duration or estimated length of need for the item;

(8) enrolled prescribing provider's signature and order signature date;

(9) number of refills, if applicable; and

(10) date of the face-to-face examination as required under (s) of this section if prescribing durable medical equipment, medical supplies, or related items and services.

(u) A prescription order for durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, and related items and services that require a certificate of medical necessity form may be part of the certificate of medical necessity, if the certificate of medical necessity includes all of the components of a prescription order as described in (t) of this section.

(v) The clinical assessment of need portion of a certificate of medical necessity that contains a prescription order for durable medical equipment, prefabricated off-the-shelf orthotics, medical supplies, or related items and services may not be prepared by a supplier of durable medical equipment, prefabricated off-the-shelf orthotics, medical supplies, or related items and services to the prescriber.

(w) The department will not pay for durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services if they were prescribed more than one year before a claim for payment is submitted. For the purposes of payment, a prescription order written and signed by the prescriber after a product has been dispensed will not be accepted.

(x) A prescriber shall sign a prescription or affix to a prescription an authenticated digital signature from an electronic health record system. The department will not accept a signature stamp or a copy of a signature as part of a valid prescription order even if affixed to the prescription order by the prescriber. The department will accept a prescription order or certificate of medical necessity received by facsimile with the prescriber's original or authenticated digital signature.

7 AAC 120.200

Eff. 2/1/2010, Register 193; am 7/7/2010, Register 195; am 6/2/2019, Register 230, May 2019

The United States Food and Drug Administration, Center for Drug Evaluation and Research's national drug code compilation referred to in 7 AAC 120.200(h) is available at the following Internet address: http://www.fda.gov/Drugs/hiformationOnDrugs/ucm142438.htm

Information on how to enroll with Medicare may be obtained from the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) at the following Internet address: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-MedicaidCoordination.html

Authority:AS 47.05.010

AS 47.05.015

AS 47.07.030

AS 47.07.040