7 AAC 105.130 - Services requiring prior authorization
(a) Except as
otherwise provided in 7 AAC 105 - 7 AAC 160, the department will not pay for
the following services unless the department has given prior authorization for
the service:
(1) nonemergency, medically
necessary transportation and accommodation services;
(2) a specific health care service for which
prior authorization is specifically required under 7 AAC 105 - 7 AAC
160;
(3) a service that exceeds an
annual or periodic service limitation established in 7 AAC 105 - 7 AAC
160;
(4) an item of durable medical
equipment, supplies, or hearing items identified in 7 AAC 105 - 7 AAC 160 as
requiring prior authorization;
(5)
respiratory therapy;
(7) home infusion therapy services;
(8) private-duty nursing services;
(9) hospice care services;
(10) magnetic resonance imaging (MRl),
magnetic resonance angiogram (MRA), single-photon emission computerized
tomography (SPECT), and positron emission tomography (PET);
(11) an inpatient or outpatient procedure or
diagnosis, regardless of the length of stay, identified in the English
description of diagnoses and procedures in the Select Diagnoses and
Procedures Pre-certification List, adopted by reference in
7
AAC 160.900;
(12) an inpatient hospital continued stay
that exceeds an applicable limitation in
7
AAC 140.320 on length of hospitalization;
(13) a prescription drug identified on the
Alaska Medicaid Prior-authorized Medications List, adopted by
reference in
7
AAC 160.900;
(14) an inpatient psychiatric hospital
admission in accordance with
7
AAC 140.360;
(15) a residential psychiatric treatment
center admission or continued stay in accordance with
7
AAC 140.405;
(16) an administrative-wait or swing-bed stay
at a general acute care hospital;
(17) a long-term care facility admission or
continued stay;
(18) home and
community-based waiver services under 7 AAC 130;
(20) behavioral health services identified in
7 AAC 135 as requiring prior authorization.
(21) surgical procedures to alter a
recipient's body to conform to the recipient's gender identity;
(22) therapy services identified in
7
AAC 115.110,
7
AAC 115.210,
7
AAC 115.310, and
7
AAC 115.410 as requiring prior
authorization.
(b) Except
as provided in
7
AAC 140.320, failure to obtain the required prior
authorization may result in nonpayment, regardless of the eligibility of the
recipient or the appropriateness of the services.
(c) For prior authorization, factors that the
department will consider include the service's medical necessity, clinical
effectiveness, cost-effectiveness, and likelihood of adverse effects, as well
as service-specific requirements in 7 AAC 105 - 7 AAC 160. The department may
place minimum or maximum quantities allowed of a specific service, may require
other services before the recipient receives the requested service, or may
require prior authorization for other services, as necessary
(1) for the protection of the public health,
safety, and welfare;
(2) to prevent
waste, fraud, and abuse of the Medicaid program; or
(3) to maintain the financial integrity of
the department and the Medicaid program.
(d) The department may pay for a service
under (a) of this section without prior authorization if prior authorization
was not possible before the service was provided or a claim for payment is
being processed after the service was provided following determination of a
recipient's retroactive eligibility under
7
AAC 100.072.
Notes
Authority: AS 47.05.010
AS 47.07.030
AS 47.07.040
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