7 AAC 43.085. Provider appeals

(a) A provider may appeal the decision of the division to deny the payment of a claim based on the provider's failure to file the claim before the billing deadline set out in 7 AAC 43.025(c) . The provider may appeal the decision by submitting a written request to the division no later than 60 days after the date on which the payment of the claim was denied. In an appeal by a provider under this subsection, the division shall

(1) make full payment to the provider of the allowable charges presented in the claim if the division determines that

(A) payment of the claim was denied due to an error by the division; or

(B) the claim was otherwise timely filed;

(2) approve the payment to the provider of the allowable charges presented in the claim if the division determines that the provider has shown good cause for the provider's failure to submit the claim before the billing deadline set out in 7 AAC 43.025(c) ; or

(3) deny the provider's appeal if the division cannot make a determination under (1) or (2) of this subsection.

(b) A provider may appeal the decision of the division's designee under 7 AAC 43.083 upholding the division's decision to deny or reduce the payment of a claim. The provider may appeal the decision by submitting a written request to the division no later than 60 days after the date of the designee's determination under 7 AAC 43.083(d) . The decision on appeal under this subsection is a final decision.

(c) A provider may appeal a determination of hospital admission or a length of stay determination that, under this chapter, requires prior approval by a professional review organization. The provider may appeal the decision by submitting a written request to the division no later than 60 days after the date of the organization's determination. The decision on appeal under this subsection is a final decision.

(d) A provider may appeal a decision by the division to recover an overpayment under 7 AAC 43.081(b) (2) by submitting a written request to the division no later than 60 days after the date of the division's notice under 7 AAC 43.081(d) .

(e) A provider making an appeal under (a) - (d) of this section shall submit the appeal to the Division of Medical Assistance, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska, 99503-7167.

(f) A provider may appeal the decision of the division on an appeal made under (a) of this section to the commissioner. The provider may appeal the decision by submitting a written request to the commissioner no later than 60 days after the date of the division's determination made under (a) of this section. A provider making an appeal under this subsection shall submit the appeal to the Commissioner of Health and Social Services, P.O. Box 110601, Juneau, Alaska 99811-0601.

(g) A provider that appeals a decision under (a) - (d) or (f) of this section shall include in the appeal a clear description of the issue or decision being appealed and the reason for the appeal.

(h) The division, for an appeal under (a) - (d) of this section, or the commissioner, for an appeal under (f) of this section, may not consider an appeal that is submitted after the last day on which the appeal may be taken.

(i) A provider may appeal the results of an audit or review conducted under 7 AAC 43.067. The appeal must be submitted to the commissioner within 30 days after the provider receives the results and must include

(1) a clear description of the issue or decision being appealed;

(2) the reason for the appeal; and

(3) all information and materials that the provider requests the commissioner to consider in resolving the appeal.

History: Eff. 8/18/79, Register 71; readopt 8/7/96, Register 139; am 11/29/97, Register 144; am 6/26/98, Register 146; am 3/3/2001, Register 157; am 6/19/2004, Register 170

Authority: AS 44.77.015

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