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;

(6) home health care services under 7 AAC 125.300 - 7 AAC 125.399;

(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;

(19) personal care services under 7 AAC 125.010 - 7 AAC 125.199;

(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.

(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

7 AAC 105.130

Eff. 2/1/2010, Register 193; am 10/1/2011, Register 199; am 3/19/2014, Register 209, April 2014; am 7/25/2021, Register 239, October 2021

Authority:AS 47.05.010

AS 47.07.030

AS 47.07.040