7 AAC 145.025 - Payment for services provided out of state

(a) Unless otherwise provided in 7 AAC 105 - 7 AAC 160, the department will pay an out-of-state enrolled provider at the lowest of

(1) the billed charges;

(2) 70 percent of the in-state rate identified in 7 AAC 105 - 7 AAC 160 for the specific type of provider; or

(3) the rate established by the Medicaid agency in the jurisdiction where the service was provided, if the rate information is available.

(b) The department may negotiate a specific payment agreement for unique expertise, for specialized services not available in this state, or for specific services that are necessary to treat the recipient. Factors that the department will consider in making the decision to negotiate a specific payment agreement under this subsection include

(1) the medical necessity for the out-of-state service;

(2) whether the service is widely available out of state or available only from a limited number of out-of-state providers;

(3) the professional standing of the provider within the health care services community for the unique expertise or specialized service;

(4) any extreme circumstance concerning the medical needs of the patient; and

(5) whether a specific payment agreement is necessary to ensure access to appropriate medical services that otherwise would not be available.

(c) The specific payment agreement under (b) of this section is not available for general services offered by the provider and is limited to the specific services set out in the payment agreement. General services offered by the provider and not associated with unique expertise or the specialized services outlined in the payment agreement will be paid under (a) of this section.

(d) The specific payment agreement under (b) of this section must be for a specific period of time, not to exceed two years.

(e) Except as provided in this section, the department will process claims for out-of-state services in accordance with the claim process established for the applicable types of provider in this state under 7 AAC 105 - 7 AAC 160.

(f) Charges to the department for out-of-state services may not exceed the provider's usual and customary charges for the same service to the general public.

(g) For state fiscal year 2020, the department will pay state fiscal year 2019 Alaska Medicaid payment rates for out of state transportation and accommodation services under 7 AAC 120.405 and 7 AAC 120.425, with the exception of transportation services under 7 AAC 120.405(d), emergency transportation services under 7 AAC 120.415, and air ambulance services under 7 AAC 120.420.

Notes

7 AAC 145.025

Eff. 2/1/2010, Register 193; am 7/1/2019, Register 233, January 2019

Authority:AS 47.05.010

AS 47.07.040