Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 385. Non-covered hospital services

7 AAC 43.385. Non-covered hospital services

In addition to the exclusions set out in 7 AAC 43.010, certain services are not reimbursable to hospitals. Services identified as non-reimbursable in the revenue code sections for inpatient hospital services and outpatient hospital services, as revised as of September 2005, adopted by reference, and set out in the Outpatient Hospital Services section of the Alaska Medicaid Provider Billing Manual , and as revised as of April 15, 2005, adopted by reference, and set out in the Indian Health Service (IHS)/Tribal Facility Services section of the Alaska Medicaid Provider Billing Manual , are not covered, including services provided by tribal facilities. Other non-covered hospital services and procedures include

(1) a service that is not within the scope of the facility's licensure, certification, or accreditation;

(2) the following services, unless the department gives prior authorization specifically for the service:

(A) the dispensing of antabuse;

(B) methadone treatment, including the dispensing of methadone;

(C) alcohol or drug detoxification or rehabilitation;

(3) leaves of absence, including charges for holding a recipient's room or bed, except as described under 7 AAC 43.260 when a recipient is in a hospital's long-term care facility;

(4) services and procedures that do not require hospital care, such as

(A) rest cures, daily respite care under 7 AAC 43.1049, adult day services, or day care for children;

(B) room and board for individuals other than the patient, unless the department gives prior authorization specifically for the service;

(C) admission solely for the purpose of medical and dental services, surgical procedures, or diagnostic testing that can be performed on an outpatient basis or in an outpatient surgical care center; however, the department may give prior authorization specifically for a service, procedure, or test if the recipient's

(i) current medical condition or physical or mental disabilities are sufficiently severe that performing that service, procedure, or test on an outpatient basis or in an outpatient surgical care center would seriously endanger the recipient's health; or

(ii) recent medical history indicates that performing that service, procedure, or test on an outpatient basis or in an outpatient surgical care center would seriously endanger the recipient's health;

(D) recipients who no longer require acute inpatient care; however, the department will make payment to the hospital for accommodation when no long-term care bed is available at the level of care appropriate for the recipient;

(E) custodial care related to court commitments; patients confined to a hospital under a court commitment for any reason will be covered for payment only to the extent medical necessity exists for inpatient hospital care;

(F) recipients remaining beyond the length of stay authorized under 7 AAC 43.395;

(G) recipients pending discharge when hospital care is no longer required; and

(H) days of care due to failure to promptly request or perform necessary diagnostic studies, medical-surgical procedures, or consultations;

(5) organ transplants and related services, and dental implants, except that the department may make payment for organ transplants and requisite related medical care for

(A) kidney and corneal transplants; prior authorization is not required;

(B) skin and bone transplants for which the department has given prior authorization; however, dental implants are not covered;

(C) bone marrow transplants for which the department has given prior authorization;

(D) liver transplants for which the department has given prior authorization, for persons with biliary atresia or other forms of end-stage liver disease;

(E) heart transplants and heart-lung transplants for which the department has given prior authorization, for persons under age 21.

History: Eff. 8/18/79, Register 71; am 6/28/85, Register 94; am 12/31/92, Register 124; am 9/1/94, Register 131; readopt 8/7/96, Register 139; am 10/12/97, Register 144; am 5/15/2004, Register 170; am 12/2/2005, Register 176

Authority: AS 47.05.010

AS 47.07.030

AS 47.07.040

Editor's note: The revenue code sections for inpatient hospital services and outpatient hospital services, as revised as of September 2005, adopted by reference in 7 AAC 43.385, and set out in the Outpatient Hospital Services section of the Alaska Medicaid Provider Billing Manual , and as revised as of April 15, 2005, adopted by reference in 7 AAC 43.385, and set out in the Indian Health Service (IHS)/Tribal Facility Services section of the Alaska Medicaid Provider Billing Manual , may be obtained by contacting the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167.

Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.385 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.