Section 7 AAC 120.300 - Enrollment of a prosthetics and orthotics provider; general provisions; covered items and services(a) To be eligible for payment under 7 AAC 105 - 7 AAC 160 for providing prosthetics, orthotics, and related items and supplies, 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 prosthetics and orthotics provider, if the provider provides prosthetics and customized orthotic devices and services;(3) maintain continuous accreditation or certification by the American Board for Certification in Orthotics, Prosthetics, and Pedorthics, the Board for Orthotist/Prosthetist Certification, the National Examining Board of Ocularists, Inc., or other similar certifying or accrediting agency approved by the department demonstrating applicable professional standards and qualifications;(4) continuously employ at least one individual who maintains the credentials of Certified Orthotist, Certified Prosthetist, Certified Prosthetist/Orthotist, or Certified Pedorthist and who is in-charge; in this paragraph, "in-charge" means that the individual has the authority and responsibility for the facility's compliance with practice standards at the enrolled provider location;(5) provide to the department evidence at initial enrollment and upon request that the provider is enrolled as a Medicare provider and Medicare enrollment is maintained concurrent with Medicaid enrollment; and(6) notify the department in writing not later than 30 days after 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 120.300 - 7 AAC 120.399, a provider enrolled under 7 AAC 105.210 as a prosthetics and orthotics provider may request payment for prosthetic or orthotic devices and services furnished to a recipient, if the item or service is (1) prescribed by a physician, physician assistant, or advanced practice registered nurse who is enrolled in accordance with 7 AAC 105.210 and acting within the scope of that person's license;(2) appropriate for use in the recipient's home or community;(3) not provided by, or under arrangements made by, a home health agency; and(4) dispensed in compliance with a valid prescription order from an individual under (1) of this subsection; if a current prosthesis needs to be repaired or modified, each of the following must be met: (A) all applicable warranties are expired;(B) the cost of the repair or modification is less than 50 percent of the cost of a new prosthesis and the provider has submitted supporting documentation; and(C) the repair has a minimum 30-day warranty.(c) A prosthetics and orthotics provider shall(1) ensure that the recipient is eligible to receive the product;(2) maintain proof of receipt for items supplied to recipients consistent with 7 AAC 105.230 and submit the proof of receipt to the department upon request; and(3) accept the return of a substandard item.(d) Due to the complexity of the information required for prosthetics and custom fabricated orthotics, a certificate of medical necessity may be prepared by the prosthetics and orthotics provider if(1) the prosthetic or custom fabricated orthotic is prescribed by the recipient's physician, physician assistant, or advanced practice registered nurse before the completion of the certificate of medical necessity by the prosthetics and orthotics provider;(2) the certificate of medical necessity is reviewed and signed by the recipient's prescribing physician, physician assistant, or advanced practice registered nurse, acknowledging concurrence with the treatment plan; and(3) documentation of the certificate of medical necessity is maintained in the recipient's medical record by the recipient's prescribing physician, physician assistant, or advanced practice registered nurse.(e) A prescription order for a prosthetic or orthotic device or service must contain the (1) recipient's name and date of birth;(2) item or service being prescribed;(4) international classification of disease code;(5) quantity of the item or service being prescribed;(6) duration or estimated length of need for the item; and(7) enrolled prescribing physician, physician assistant, or advanced practice registered nurse's signature and order signature date;(f) A prescription order for a prosthetic or orthotic device or service 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 (e) of this section.(g) A prescription order for a prosthetic or orthotic device or service, including a certificate of medical necessity serving as a prescription order, will be accepted for not more than one year from the signature date. A backdated order will not be accepted as authorization for an item supplied before the provider receiving a valid prescription order for the item. A retrospective start date for a prescription order, with current day signature, may be considered for service authorization review under 7 AAC 120.210 upon individual medical necessity and if all other state and federal regulatory provisions are met. If a retrospective start date is permitted, the prescription order only be valid for one year from the retrospective start date.(h) The prescribing physician, physician assistant, or advanced practice registered nurse's hard-copy original or authenticated digital signature must be affixed to the prescription order or the certificate of medical necessity serving as a prescription order. 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. A prescription order or certificate of medical necessity received by means of facsimile, with the prescriber's signature, may be accepted.(i) A prosthetics and orthotics provider enrolled under this section may request payment, as follows, for the reasonable direct costs of delivering or shipping prosthetics or orthotics incurred by the dispensing provider when using the most cost-effective means: (1) to be eligible for payment, 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 of prosthetics and orthotics enrolled under this section in the municipality in which the recipient resides; and(C) the item shipping from the manufacturer to the provider is durable medical equipment, prosthetics, orthotics, or unique or specialized replacement parts and for which the final unaltered purchase invoice price exceeds $250;(2) if the shipping charge submitted by the provider exceeds $50, the claim and supporting documents must include (A) the recipient's name;(B) the address the item was shipped or delivered to;(C) an itemized list of the products included in the shipment or delivery, to include product name, product identifier, quantity, and serial number, when applicable;(D) the shipment and delivery date;(E) the recipient's signature with date of receipt; and(F) the total charges minus all discounts, substantiated by a paid shipping invoice reflecting the actual payment.(j) The department will not pay separately for the costs of administrative expenses related to the provision of prosthetics and orthotics. The following costs are considered administrative expenses and are included in the payment for prosthetics and orthotics: (1) telephone responses to questions;(7) orientation and training regarding proper use of the item;(8) preparation and maintenance of necessary records required under 7 AAC 105.230 and 7 AAC120.210.(k) The department may enter into a contract under AS 36.30, a grant, or other arrangement permitted by law with a prosthetics and orthotics provider enrolled under this section, authorizing that provider to provide prosthetics or orthotics.(l) A prosthetics and orthotics provider enrolled under this section may not make unsolicited contact with a recipient of medical assistance under 7 AAC 100 for the purpose of marketing the provider's products or services.(m) A prosthetics and orthotics provider enrolled under this section may request payment for the reasonable costs of follow-up fittings and adjustments on a per 15-minute basis unless these services were included in and previously reimbursed under a bundled rate.Eff. 6/2/2019, Register 230, May 2019 Authority:AS 47.05.010
AS 47.07.030
AS 47.07.040