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(a) Unless otherwise provided in this chapter, the department will pay an out-of-state enrolled provider at the lowest of
(1) the billed charges;
(2) 70 percent of the rate identified in the fee schedule established under 7 AAC 43.108;
(3) the rate identified in a fee schedule established under this chapter for a provider type or service not covered under 7 AAC 43.108; or
(4) the rate established by the Medicaid agency in the state where the service was provided, if the rate information is available.
(b) The department may negotiate a specific payment agreement for unique expertise, for specialized services not available in this state, or for specific services that are necessary to treat the recipient. Factors that the department will consider in making the decision to negotiate a specific payment agreement under this subsection include
(1) the medical necessity for the out-of-state service;
(2) whether the service is widely available out of state or available only from a limited number of out-of-state providers;
(3) the professional standing of the provider within the health care services community for the unique expertise or specialized service;
(4) any extreme circumstance concerning the medical needs of the patient; and
(5) whether a specific payment agreement is necessary to ensure access to appropriate medical services which otherwise would not be available.
(c) The specific payment agreement under (b) of this section is not available for general services offered by the provider and is limited to the specific services set out in the payment agreement. General services offered by the provider and not associated with unique expertise or the specialized services outlined in the payment agreement will be paid under (a) of this section.
(d) The specific payment agreement under (b) of this section must be for a specific period of time not to exceed two years.
(e) Except as provided in this section, the department will process claims for out-of-state services in accordance with the claim process established for the applicable provider type in this state under this chapter.
(f) Charges to the department for out-of-state services may not exceed the provider's usual and customary charges for the same service to the general public.
History: Eff. 8/18/79, Register 71; readopt 8/7/96, Register 139; am 12/2/2005, Register 176
Authority: AS 47.05.010
Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.150 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.
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Last modified 7/05/2006