Section 7 AAC 145.005 - Conditions for payment(a) The department will pay a provider for a covered service identified in AS 47.07 and 7 AAC 105 - 7 AAC 160 only if the (1) claim is submitted by a provider who is enrolled with the department under 7 AAC 105 - 7 AAC 160;(2) services were rendered to an individual who was eligible under 7 AAC 100 at the time the service was rendered; and(3) the department gave prior authorization for the service if required under 7 AAC 105 - 7 AAC 160.(b) The payment rate established by the department for a given service, less the amount of cost-sharing required under 7 AAC 105.610, constitutes full payment from the department for that service. Except as provided in 7 AAC 110.145, a provider may not charge a recipient or recipient's relative, friend, or representative, any amount to supplement payment by the department for services to which the recipient is entitled under 7 AAC 105-7 AAC 160.(c) A provider must submit a claim to the department's contractor no more than 12 months after the date of service except as provided in this subsection. The department may extend the 12-month deadline for billing if the department determines that the provider had reason to believe that the recipient was ineligible at the time service was rendered, the recipient is subsequently determined eligible by a court, hearing authority, or the department, and the claim is filed no more than 12 months after the date the department sends notice to the recipient of the court, hearing authority, or department decision that eligibility is established. The recipient's failure to notify the provider of a court, hearing authority, or department decision is not considered good cause under 7 AAC 105.280 for failure to file a claim.(d) Except as specified in (e) of this section, when a provider furnishes a covered service to a recipient who, before receiving the service, has furnished the provider with a recipient identification card, recipient identification number, or other evidence of Medicaid eligibility, the recipient is under no obligation to pay the provider for the service other than the cost-sharing amounts required under 7 AAC 105.610. However, a recipient is liable for the full cost of the service rendered if the recipient fails to furnish a recipient identification card, recipient identification number, or other evidence of Medicaid eligibility before receiving the service.(e) If a recipient is eligible retroactively under 7 AAC 100.072, the provider is under no obligation to submit a claim to the department for a covered service furnished to the recipient during a month the recipient was found retroactively eligible. The recipient remains liable for the cost of the service rendered during a month of retroactive eligibility until the provider has been furnished evidence of eligibility and the provider has agreed to accept payment under (g) and (h) of this section and 7 AAC 145.020 by billing the department for the service. Payments made by a recipient to the provider before retroactive eligibility has been determined by the department must be handled in accordance with 7 AAC 105.250.(f) The department will deny a claim for payment if the provider fails to submit the claim in the form or format required by the department for claim submission. If a payment is denied under this section, the provider may appeal under 7 AAC 105.270.(g) By providing a service to a Medicaid recipient and billing the department for that service, a provider agrees to comply with applicable department regulations.(h) A provider may not charge (1) for any administrative cost related to participation in the Medicaid program; or(2) a higher rate for any unit of service provided to a Medicaid recipient than the provider charges others, except for an amount billed Medicare.(i) If a provider receives a payment from a recipient, relative, recipient's estate, health insurance, or other source for a service provided, and the provider intends to submit a claim to the department for the same service, the provider must report that payment and must enter it as a credit against the charge to the department.Eff. 2/1/2010, Register 193; am 5/1/2016, Register 218, July 2016; am 8/1/2020, Register 235, October 2020Authority:AS 47.05.010
AS 47.07.040
AS 47.07.042