Section 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); and(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. (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 providers 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 section.(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 A AC 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 Medicaid Management Information System (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 Medicaid Management Information System (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.Eff. 2/1/2010, Register 193; am 12/1/2011, Register 200; am 5/11/2012, Register 202; am 3/22/2014, Register 209, April 2014; am 10/1/2017, Register 223, October 2017; am 7/1/2019, Register 232, January 2019Authority:AS 47.05.010
AS 47.07.030
AS 47.07.040