Section 7 AAC 120.205 - Noncovered items and services(a) Except as provided otherwise in this section or by federal law, the department will not pay separately for durable medical equipment while the recipient is (1) in a hospital, a skilled nursing facility, or an intermediate care facility; or(2) receiving hospice care services. (b) The department will not pay separately for home infusion therapy services (1) while the recipient is in a hospital, a skilled nursing facility, or an intermediate care facility; (2) if like services, including skilled nursing visits, are provided by or under arrangements made by a home health agency;(3) if, on the same day, like services are provided by a hospital or facility during an outpatient visit; or (4) while the recipient is receiving hospice care services and the services are (A) related to the treatment of the terminal illness that qualifies the recipient for hospice care; or(B) provided by or under the arrangements made by the hospice program. (c) The department will not pay for 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) related to the treatment of the terminal illness that qualifies the recipient for hospice care; or(2) provided by or under arrangements made by the hospice program. (d) The department will not pay for the repair of durable medical equipment while the recipient is in a skilled nursing facility or an intermediate care facility. (e) The department will not pay separately for the repair, return shipping, or preventive maintenance or service of durable medical equipment for which the cost of repair, return shipping, or preventive maintenance or service is included in the rental fee.(f) The department will not pay for the repair or preventative maintenance or service of durable medical equipment for which there is no documented medical necessity that is current under 7 AAC 120.200(/) for the continued use of that item. (g) The department will not pay a provider enrolled as a durable medical equipment provider under 7 AAC 105.210 for medical supplies that are required under federal law to be provided at no cost to employees, including gloves, masks, and isolation gowns.(h) For a recipient who is eligible for both Medicare and Medicaid, (1) a provider enrolled as a durable medical equipment provider under 7 AAC 105.210 must follow Medicare guidelines for use of the Advance Beneficiary Notice of Noncoverage, Form CMS-R-131, in situations where Medicare payment is expected to be denied; (2) the department will not pay for durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200(a)(2) billed with codes exceeding the recipient's medical necessity as determined by evidence-based clinical protocols and Medicare national and local coverage determinations; and (3) the department will not pay for durable medical equipment for a Medicare-covered item, including a manual or power wheelchair, for a recipient who is eligible for both Medicare and Medicaid if Medicare has determined the equipment medically unnecessary for that recipient; a provider enrolled as a durable medical equipment provider under 7 AAC 105.210 must get a Medicare determination of medical necessity before seeking payment from the department in excess of the copay and deductible.(i) A provider may not bill for durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics or related items and services under 7 AAC 120.200(a)(2) using a miscellaneous code from the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900, if a specific code is available and appropriate. If the department pays a claim based on a provider's erroneous use of a miscellaneous code under this subsection, the department may seek recovery under 7 AAC 105.260 of payment for those services or items and impose sanctions under 7 AAC 105.400 - 7 AAC 105.490.(j) The department will not pay for durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200(a)(2) that require CMS prior authorization under 42 C.F.R. 414.234(c)(1) and for which the provider has not sought and received a service authorization under 7 AAC 120.210.(k) The department will only pay for durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200(a)(2) that require the prescriber to perform a face-to-face examination of the recipient under 42 C.F.R. 440.70 and 42 C.F.R. 410.38 if that face-to-face examination was timely performed. (l) The department will only pay for services rendered while the provider is in compliance with the provider enrollment requirements of 7 AAC 105.210.Eff. 2/1/2010, Register 193; am 7/7/2010, Register 195; am 6/2/2019, Register 230, May 2019Authority:AS 47.05.010
AS 47.07.030
AS 47.07.040