Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 1900. Enrollment; general provisions; covered items and services

7 AAC 43.1900. Enrollment; general provisions; covered items and services

(a) The department may enroll under this section a provider that provides the department with evidence that the provider holds a valid business license issued under AS 43.70 and 12 AAC 12. The department will enroll a provider under this section as either a

(1) durable medical equipment provider, if the provider provides

(A) durable medical equipment;

(B) medical supplies;

(C) respiratory therapy assessment visits;

(D) home infusion therapy services; or

(E) noncustomized-fabricated orthotics; or

(2) prosthetics and orthotics provider, regardless of whether the provider provides other items or services in (1) of this subsection, if the provider

(A) provides prosthetics and orthotics; and

(B) is certified by the American Board of Certification in Prosthetics and Orthotics.

(b) Subject to the applicable provisions of 7 AAC 43.1900 - 7 AAC 43.1980, the department will pay an enrolled provider for medically necessary durable medical equipment, medical supplies, prosthetics, orthotics, or noncustomized-fabricated orthotics furnished to a recipient, if

(1) the item

(A) is prescribed by the attending physician, physician assistant, advanced nurse practitioner, physical therapist, occupational therapist, or speech-language pathologist, acting within the scope of that person's license;

(B) is appropriate for use in the recipient's home, school, or community; and

(C) is not provided by, or under arrangements made by, a home health agency;

(2) the provider furnishes orientation and training to the recipient regarding the proper use of the item, and includes proof of compliance with this paragraph in its records; the provider shall submit this proof to the department upon request; and

(3) prior authorization, if required under 7 AAC 43.1910, is obtained from the department.

(c) Subject to the applicable provisions of 7 AAC 43.1900 - 7 AAC 43.1980, the department will pay an enrolled provider for continuous oxygen used by a recipient in a skilled nursing facility or intermediate care facility if the skilled nursing facility or intermediate care facility has not been authorized to provide continuous oxygen under 7 AAC 43.255.

(d) Subject to the applicable provisions of 7 AAC 43.1900 - 7 AAC 43.1980, the department will pay for the purchase or rental of durable medical equipment for a recipient in a skilled nursing facility or intermediate care facility if the purchase or rental is medically necessary for the recipient's preparation for discharge or for the actual discharge to home. A rental or purchase may not be arranged sooner than 30 days before the scheduled discharge and will be given prior authorization only if the equipment is not provided by the skilled nursing facility or intermediate care facility. The department may pay for trial use of rental equipment necessary for preparing a recipient for discharge.

(e) Subject to the applicable provisions of 7 AAC 43.1900 - 7 AAC 43.1980, the department will pay an enrolled provider under this section for home infusion therapy services if the services are

(1) ordered by

(A) the attending physician as part of a written home health plan of care under 7 AAC 43.801; or

(B) a physician as part of a written hospice plan of care under 7 AAC 43.938(d) ;

(2) reviewed at least every 60 days by the attending physician to determine the ongoing medical need for the service; and

(3) is appropriate for use in the recipient's home, school, or community.

(f) Subject to applicable provisions of 7 AAC 43.1900 - 7 AAC 43.1980, the department will pay a provider under this section for medically necessary medical supplies or respiratory therapy assessment visits furnished to a recipient who is receiving hospice care services, if the supplies or assessment visits are

(1) ordered by a physician as part of a written hospice plan of care and the physician reviews the recipient's continuing medical need for the items; and

(2) appropriate for use in the recipient's home, school, or community.

(g) Subject to the applicable provisions of 7 AAC 43.1900 - 7 AAC 43.1980, the department will pay an enrolled provider for the following items if described by a national drug code (NDC):

(1) skin sealant;

(2) skin protectant;

(3) skin moisturizer;

(4) skin ointment;

(5) skin cleanser;

(6) skin sanitizer.

(h) The department will pay an enrolled provider for the reasonable and necessary costs of delivery and dispensing expenses incurred in the delivery of the items from the dispensing provider to the recipient if the recipient resides outside the municipality where the business of the enrolled servicing provider is located and the item is unavailable in the municipality in which the recipient resides. If the charge is over $50, the provider must submit

(1) an electronic claim, supported by

(A) the recipient's name;

(B) the recipient's address;

(C) information, such as a serial number, that identifies the item;

(D) the delivery date; and

(E) the total charges; or

(2) a paper claim, including an invoice that shows

(A) the recipient's name;

(B) the recipient's address;

(C) information, such as a serial number, that identifies the item;

(D) the delivery date; and

(E) the total charges.

(i) The department will not pay separately for the costs of administrative expenses. The following costs are considered administrative expenses and are included in the payment for the durable medical equipment, medical supplies, prosthetics, orthotics, and noncustomized-fabricated orthotics:

(1) telephone responses to questions;

(2) mileage;

(3) travel expenses;

(4) travel time;

(5) setting up an item;

(6) installation;

(7) orientation and training regarding the proper use of the item.

(j) A prescribing provider under (b)(1)(A) of this section shall review the continued medical necessity for the durable medical equipment, supplies, prosthetics, or orthotics annually. The department may require more frequent or less frequent reviews based on the nature of the item prescribed.

(k) A provider of durable medical equipment, medical supplies, prosthetics, orthotics, or noncustomized-fabricated orthotics shall

(1) document a recipient's request for a 30-day refill;

(2) accept returns from recipients of any substandard item; for purposes of this paragraph, "substandard item" means an item that does not function in a manner that meets the prescribed need or specifications; and

(3) upon request, provide proof, in the form of copies of letters, logs, or signed notices, that it has provided Medicaid recipients with warranty information for Medicaid-covered items.

( l ) The department will only pay for medical supplies that are required for a 30-day period. The department may seek recovery under 7 AAC 43.081 of payment for services or items determined to be medically unnecessary and impose sanctions under 7 AAC 43.950(8) .

(m) The department may enter into a contract under AS 36.30, a grant, or other arrangement permitted by law, with an enrolled provider authorizing that provider to

(1) provide durable medical equipment, medical supplies, prosthetics, orthotics, or noncustomized-fabricated orthotics; or

(2) serve a specific geographic region and provide incontinence supplies, including

(A) garments;

(B) liners;

(C) underpads;

(D) nonsterile gloves;

(E) diaper wipes; and

(F) disposable washcloths.

History: Eff. 1/11/2006, Register 177

Authority: AS 47.05.010

AS 47.05.015

AS 47.07.030

AS 47.07.040

Editor's note: The United States Food and Drug Administration, Center for Drug Evaluation and Research's national drug code compilation referred to in 7 AAC 43.1900(g) is available at the following Internet address: www.fda.gov/cder/ndc/index.htm.