7 AAC 140.315 - Noncovered hospital services

(a) Except as otherwise provided in 7 AAC 105 - 7 AAC 160, the department will not pay for services

(1) identified as noncovered services in 7 AAC 105.110; or

(2) for which a revenue code is not listed as described in 7 AAC 140.310(a).

(b) Except as otherwise provided in 7 AAC 105 - 7 AAC 160, the department will not pay a hospital for the following services and procedures:

(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) tobacco cessation therapy and services; however, the department will pay for tobacco cessation products;

(4) leaves of absence, including charges for holding a recipient's room or bed, except as described under 7 AAC 140.585 when a recipient is in a hospital's long-term care facility;

(5) services and procedures that do not require hospital care, including

(A) outpatient special residence charges, rest cures, daily respite care under 7 AAC 130.280, 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 ambulatory surgical center; however, the department will 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 ambulatory surgical 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 ambulatory surgical center would seriously endanger the recipient's health;

(D) recipients who do not require or who no longer require acute inpatient care; however, the department will make a payment to the hospital for accommodation when no long-term care bed is available, if the department has approved the level of care appropriate for the recipient in situations involving a swing bed or administrative-wait bed;

(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 140.320;

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

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

(I) disability examinations, except that the department will pay for outpatient tests ordered by a physician as part of

(i) an initial disability examination in accordance with 7 AAC 40.180; or

(ii) a review of a disability determination in accordance with 7 AAC 40.190;

(J) evaluative or periodic checkups, examinations, or immunizations that are connected with the participation in, enrollment in, attendance at, or accomplishment of a program or activity unrelated to the recipient's physical or mental health or rehabilitation, except mammograms;

(6) organ transplants and related services, and dental implants, except that the department will 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;

(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; and

(E) heart, lung, and heart-lung transplants for which the department has given prior authorization;

(7) weekend stays if admission was made on Friday or Saturday for surgery scheduled on Monday, except for an emergency or situation where the physical or mental condition of the patient necessitates extensive preoperative preparation or therapy;

(8) professional fees in addition to those typically charged within specific cost centers, including osteopathic services, and except registered nurse anesthetist services;

(9) separately identifiable preventive care services, clinic services, medical social services, and trauma team response activation charges;

(10) nursing services and incremental nursing charges assessed in addition to accommodation charges, including private-duty nursing charges;

(11) take-home drugs, oxygen, and supplies not otherwise classified;

(12) home infusion therapy;

(13) miscellaneous home dialysis charges;

(14) educational services and supplies;

(15) cardiac rehabilitation that exceeds the guidelines in the Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.10 (Cardiac Rehabilitation Programs), adopted by reference in 7 AAC 160.900;

(16) recreational therapy and medical rehabilitation day programs;

(17) charges for services or items normally considered part of routine services and optional or special services not directly related to medical care, including

(A) private accommodation charges, unless medically necessary;

(B) deluxe accommodation charges;

(C) patient convenience items; and

(D) routine service charges for accommodations that cannot be included in more specific revenue codes;

(18) personal services not normally associated with hospital care, including long-distance telephone calls, television rental, guest meals, and personal items.

(c) The department will not pay for a service or inpatient stay for which prior authorization is denied, or is required but not obtained, including nonemergency out-of-state services for which prior authorization is not obtained under 7 AAC 105.130.

(d) Repealed 3/19/2014.

(e) Except as provided in (f) of this section, the department will not pay a hospital for the following provider-preventable conditions:

(1) services and procedures related to a health care-acquired condition as defined in 42 C.F.R. 447.26(b), adopted by reference in 7 AAC 160.900;

(2) a wrong surgical or other invasive procedure performed on a patient;

(3) a surgical or other invasive procedure performed on the wrong body part;

(4) a surgical or other invasive procedure performed on the wrong patient.

(f) A reduction in payment resulting from a provider-preventable condition identified in (e) of this section will be abrogated in accordance with 42 C.F.R. 447.26(c)(2) or limited in accordance with 42 C.F.R. 447.26(c)(3). The provisions of 42 C.F.R. 447.26(c) are adopted by reference in 7 AAC 160.900.

(g) In this section, "cost center" has the meaning given in 7 AAC 150.990.

Notes

7 AAC 140.315

Eff. 2/1/2010, Register 193; am 3/19/2014, Register 209, April 2014

Authority:AS 47.05.010

AS 47.07.030

AS 47.07.040