7 AAC 43.1910. Prior authorization

(a) A provider seeking prior authorization must make a request electronically or in writing on a certificate of medical necessity.

(b) Prior authorization is required for

(1) the rental of durable medical equipment;

(2) medical supplies that exceed a 30-day limit set by the department; the department will set the 30-day limit based on the 75th percentile of recipient use in calendar year 2004, and will review the limit at least biennially thereafter;

(3) requests that exceed the maximum allowable payment for durable medical equipment, medical supplies, noncustomized-fabricated orthotics, prosthetics, or orthotics under 7 AAC 43.1920;

(4) customized durable medical equipment;

(5) the following incontinence supplies:

(A) garments;

(B) liners;

(D) nonsterile gloves;

(E) diaper wipes;

(F) disposable washcloths;

(6) the following items:

(A) skin sealant;

(B) skin protectant;

(D) skin ointment;

(E) skin cleansers;

(F) skin sanitizers;

(7) items that are listed on the department's Durable Medical Equipment Prior Authorization List, dated August 2005, and adopted by reference;

(8) items that are identified as miscellaneous in the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services's (CMS) Healthcare Common Procedure Coding System (HCPCS) 2005, as amended from time to time and adopted by reference;

(9) respiratory therapy assessment visits for ventilator-dependent recipients;

(10) home infusion therapy;

(11) enteral and oral nutritional products;

(12) the purchase of durable medical equipment for a recipient in a skilled nursing facility or intermediate care facility;

(13) continuous oxygen for a recipient in a skilled nursing facility or intermediate care facility; and

(14) the purchase of durable medical equipment if the charge to the department is over $1,000.

(1) a certificate of medical necessity completed by the attending

(A) physician;

(B) physician assistant;

(D) physical therapist;

(E) occupational therapist; or

(F) speech-language pathologist;

(2) a written statement by the person under (1) of this subsection that the recipient's condition requires the more costly durable medical equipment, medical supply, noncustomized-fabricated orthotics, prosthetics, or orthotics if the request is for payment that exceeds the maximum allowable payment under 7 AAC 43.1920; and

(3) documentation by the person under (1) of this subsection that the item or service is necessary to treat, correct, or ameliorate a defect, condition, or physical or mental illness if the recipient is under 21 years of age.

(d) In addition to the requirements of (c) of this section, a prior authorization request for the following durable medical equipment or medical supplies must include, if available for the item, manufacturer information, the item description or number, the global trade item number (GTIN), the suggested list price, the serial number, and the national drug code (NDC):

(1) items that are identified as miscellaneous in Healthcare Common Procedure Coding System (HCPCS) 2005 , as amended from time to time and adopted by reference in (b) of this section;

(2) customized durable medical equipment;

(3) requests that exceed the maximum allowable payment under 7 AAC 43.1920 for the item;

(4) the following items:

(A) skin sealant;

(B) skin protectant;

(D) skin ointment;

(E) skin cleanser;

(F) skin sanitizer.

(e) Based on its review under this section, the department will give prior authorization if

(1) documentation under (c) and (d) of this section has been provided, as applicable;

(2) payment is appropriate under this chapter; and

(3) the information reviewed otherwise supports approval of the request.

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 certificate of medical necessity form referred to in 7 AAC 43.1910(a) and (c) may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167.

The United States Food and Drug Administration, Center for Drug Evaluation and Research's national drug code compilation referred to in 7 AAC 43.1910(d) is available at the following Internet address: www.fda.gov/cder/ndc/index.htm.

The United States Department of Health and Human Services, Centers for Medicare and Medicaid Services's (CMS) Healthcare Common Procedure Coding System (HCPCS) 2005, adopted by reference in 7 AAC 43.1910, may be obtained by contacting the American Medical Association at P.O. Box 930876, Atlanta, GA 31193, or by visiting their Internet address: https://catalog.ama-assn.org/Catalog/home.jsp. A copy of the HCPCS is available for examination at the Department of Health and Social Services, Division of Health Care Services, 350 Main St., Juneau, Alaska 99801.

The Durable Medical Equipment Prior Authorization List, adopted by reference in 7 AAC 43.1910(b)(7) may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167.

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