Section 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 1-5 through 1-9, 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 {effective date of regulations} 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 1-5 through 1-9, 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 1-5 through 1-9, 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 1-5 through 1-9, 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 1-5 through 1-9, adopted by reference in 7 AAC 160.900: (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 1-5 through 1-9, 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 1-5 through 1-9, 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 1-5 through 1-9, 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 1-5 through 1-9, 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 1-5 through 1-9, 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 (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 1-5 through 1-9, 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 1-5 through 1-9, 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. Eff. 2/1/2010, Register 193; am 7/7/2010, Register 195; am 6/2/2019, Register 230, May 2019 Authority:AS 47.05.010
AS 47.07.030
AS 47.07.040