7 AAC 72.530 - Application for financial assistance

(a) An application for assistance that is submitted under AS 47.31.015(a) must include
(1) a copy of the invoice for the services for which financial assistance is sought;
(2) proof of gross monthly household income; this proof includes paycheck stubs, tax records, unemployment check stubs, a signed statement from an employer, or any other document that shows evidence of income for the month during which a patient received care provided by a designated facility; and
(3) identification of and information about any third-party payor that provides insurance coverage to the patient; for purposes of this paragraph, the following persons are not third-party payors under AS 47.31.010:
(A) the United States Department of Interior, Bureau of Indian Affairs;
(B) the United States Department of Health and Human Services, Indian Health Service;
(C) the patient's private insurance company, if the company does not cover mental health inpatient treatment or the maximum benefit level for that treatment has been reached.
(b) If a designated facility makes a notification under AS 47.31.015(b), the notification must
(1) be signed and submitted by the administrator; and
(2) include
(A) any information as to whether a thirty-party payor is responsible for payment; and
(B) subject to the disclosure restrictions of 42 C.F.R. Part 2 for a patient who is also being treated for alcohol or drug abuse in a facility that receives federal assistance as described in 42 C.F.R. Part 2, a copy of the invoice for the services for which financial assistance is sought.
(c) If the facility receives payment from a patient or a third-party payor after being reimbursed by the department under this chapter, the administrator shall return the money to the department.


7 AAC 72.530
Eff. 3/16/2001, Register 157; am 6/24/2004, Register 170

Authority:AS 47.30.660

AS 47.31.015

AS 47.31.090

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