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Introduction to Alaska Medical Assistance December 2020
2
Overview
bull Alaska Medical Assistance
bull Contractors
bull Providers
bull Members
bull Resources
bull Services
bull Billing
3
Alaska Medical Assistance
4
Alaska Medical Assistance
Alaska Medical Assistance is comprised of Medicaid Denali KidCare (DKC) and Chronic
and Acute Medical Assistance (CAMA) and provides health coverage to eligible Alaskans
bull The term ldquoAlaska Medicaidrdquo is used to refer to both Alaska Medicaid and DKC
bull The Department of Health and Social Services (DHSS) administers the Alaska
Medical Assistance Program
bull Alaska Medicaid (including DKC) is jointly funded by the federal government and the
State of Alaska
bull A Medicaid fiscal agent is a contractor that processes and pays provider claims
Conduent Health is Alaska Medicaidrsquos fiscal agent
5
Federal and State Regulations
Many federal and state regulations govern the Alaska Medical Assistance program
bull Code of Federal Regulations (CFR)
ndash Title 42 - Public Health
ndash httpwwwecfrgov
bull Alaska State Statutes
ndash httpwwwlegisstateakusbasisfolioasp
bull Alaska Administrative Code
ndash Title 7 ndash Health amp Social Services gt Part 8 ndash Medicaid Coverage and Payment
ndash Chapters 105 ndash 160 ndash Medical Assistance
ndash Chapter 48 ndash Chronic and Acute Medical Assistance (CAMA)
ndash httpwwwlegisstateakusbasisfolioasp
6
Federal Oversight
The US Department of Health amp Human Services (HHS) governs all state Medicaid
programs through the Centers for Medicare amp Medicaid Services (CMS)
bull CMS administers federally funded health benefit programs including
ndash Health Insurance Marketplace (aka federal Health Insurance Exchange)
ndash Medicare - Title XVIII of Social Security Act
ndash Medicaid - Title XXI of Social Security Act
ndash Childrenrsquos Health Insurance Program (CHIP)
7
State Oversight
The Alaska Department of Health amp Social Services provides state-level oversight of the
Alaska Medical Assistance program through the following divisions
bull Office of the Commissioner
ndash Office of Rate Review
ndash Office of Program Integrity
bull Division of Public Assistance (DPA)
bull Division of Health Care Services (DHCS)
bull Division of Behavioral Health (DBH)
bull Division of Senior and Disabilities Services (DSDS)
httpdhssalaskagovPagesdefaultaspx
8
Office of the Commissioner
Oversees
bull Divisions of the Department of Health and Social Services
bull Office of Program Integrity
bull Office of Rate Review
httpdhssalaskagovCommissionerPagesdefaultaspx
9
Division of Public Assistance
bull Determines eligibility for most Alaska Medical Assistance programs as well as food
stamps cash assistance childcare and other programs
bull Issues Alaska Medical Assistance couponscards
bull Oversees Women Infant amp Children (WIC) program
httpdhssalaskagovdpaPagesdefaultaspx
10
Division of Health Care Services
Oversees
bull Provider professional facility pharmacy ancillary and other services
bull Tribal Health program
bull Member services
bull Care Management Program (CMP)
bull Systems Maintenance amp Data Analysis Unit
bull Provider second-level appeals and member fair hearings
bull Fiscal Agent oversight (Conduent)
bull Pharmacy contractor (Magellan Medicaid Administration)
bull Utilization management and case management contract oversight (Comagine Health)
bull Vision care contract oversight (Classic Optical)
httpdhssalaskagovdhcsPagesdefaultaspx
11
Division of Behavioral Health
Oversees
bull Outpatient mental health programs inpatient psychiatric care residential psychiatric
services
bull Substance abuse rehabilitation program certification
bull Behavioral Health program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdbhPagesdefaultaspx
12
Division of Senior and Disabilities Services (DSDS)
Oversees
bull Level of care determinations authorization of services and quality assurance for Home amp
Community Based Services (HCBS) Waiver and Personal Care Assistance (PCA)
programs
bull Provider certification for both HCBS and PCA programs
bull All long-term care (LTC) stay authorizations
bull Program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdsdsPagesdefaultaspx
13
Contractors
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
2
Overview
bull Alaska Medical Assistance
bull Contractors
bull Providers
bull Members
bull Resources
bull Services
bull Billing
3
Alaska Medical Assistance
4
Alaska Medical Assistance
Alaska Medical Assistance is comprised of Medicaid Denali KidCare (DKC) and Chronic
and Acute Medical Assistance (CAMA) and provides health coverage to eligible Alaskans
bull The term ldquoAlaska Medicaidrdquo is used to refer to both Alaska Medicaid and DKC
bull The Department of Health and Social Services (DHSS) administers the Alaska
Medical Assistance Program
bull Alaska Medicaid (including DKC) is jointly funded by the federal government and the
State of Alaska
bull A Medicaid fiscal agent is a contractor that processes and pays provider claims
Conduent Health is Alaska Medicaidrsquos fiscal agent
5
Federal and State Regulations
Many federal and state regulations govern the Alaska Medical Assistance program
bull Code of Federal Regulations (CFR)
ndash Title 42 - Public Health
ndash httpwwwecfrgov
bull Alaska State Statutes
ndash httpwwwlegisstateakusbasisfolioasp
bull Alaska Administrative Code
ndash Title 7 ndash Health amp Social Services gt Part 8 ndash Medicaid Coverage and Payment
ndash Chapters 105 ndash 160 ndash Medical Assistance
ndash Chapter 48 ndash Chronic and Acute Medical Assistance (CAMA)
ndash httpwwwlegisstateakusbasisfolioasp
6
Federal Oversight
The US Department of Health amp Human Services (HHS) governs all state Medicaid
programs through the Centers for Medicare amp Medicaid Services (CMS)
bull CMS administers federally funded health benefit programs including
ndash Health Insurance Marketplace (aka federal Health Insurance Exchange)
ndash Medicare - Title XVIII of Social Security Act
ndash Medicaid - Title XXI of Social Security Act
ndash Childrenrsquos Health Insurance Program (CHIP)
7
State Oversight
The Alaska Department of Health amp Social Services provides state-level oversight of the
Alaska Medical Assistance program through the following divisions
bull Office of the Commissioner
ndash Office of Rate Review
ndash Office of Program Integrity
bull Division of Public Assistance (DPA)
bull Division of Health Care Services (DHCS)
bull Division of Behavioral Health (DBH)
bull Division of Senior and Disabilities Services (DSDS)
httpdhssalaskagovPagesdefaultaspx
8
Office of the Commissioner
Oversees
bull Divisions of the Department of Health and Social Services
bull Office of Program Integrity
bull Office of Rate Review
httpdhssalaskagovCommissionerPagesdefaultaspx
9
Division of Public Assistance
bull Determines eligibility for most Alaska Medical Assistance programs as well as food
stamps cash assistance childcare and other programs
bull Issues Alaska Medical Assistance couponscards
bull Oversees Women Infant amp Children (WIC) program
httpdhssalaskagovdpaPagesdefaultaspx
10
Division of Health Care Services
Oversees
bull Provider professional facility pharmacy ancillary and other services
bull Tribal Health program
bull Member services
bull Care Management Program (CMP)
bull Systems Maintenance amp Data Analysis Unit
bull Provider second-level appeals and member fair hearings
bull Fiscal Agent oversight (Conduent)
bull Pharmacy contractor (Magellan Medicaid Administration)
bull Utilization management and case management contract oversight (Comagine Health)
bull Vision care contract oversight (Classic Optical)
httpdhssalaskagovdhcsPagesdefaultaspx
11
Division of Behavioral Health
Oversees
bull Outpatient mental health programs inpatient psychiatric care residential psychiatric
services
bull Substance abuse rehabilitation program certification
bull Behavioral Health program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdbhPagesdefaultaspx
12
Division of Senior and Disabilities Services (DSDS)
Oversees
bull Level of care determinations authorization of services and quality assurance for Home amp
Community Based Services (HCBS) Waiver and Personal Care Assistance (PCA)
programs
bull Provider certification for both HCBS and PCA programs
bull All long-term care (LTC) stay authorizations
bull Program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdsdsPagesdefaultaspx
13
Contractors
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
3
Alaska Medical Assistance
4
Alaska Medical Assistance
Alaska Medical Assistance is comprised of Medicaid Denali KidCare (DKC) and Chronic
and Acute Medical Assistance (CAMA) and provides health coverage to eligible Alaskans
bull The term ldquoAlaska Medicaidrdquo is used to refer to both Alaska Medicaid and DKC
bull The Department of Health and Social Services (DHSS) administers the Alaska
Medical Assistance Program
bull Alaska Medicaid (including DKC) is jointly funded by the federal government and the
State of Alaska
bull A Medicaid fiscal agent is a contractor that processes and pays provider claims
Conduent Health is Alaska Medicaidrsquos fiscal agent
5
Federal and State Regulations
Many federal and state regulations govern the Alaska Medical Assistance program
bull Code of Federal Regulations (CFR)
ndash Title 42 - Public Health
ndash httpwwwecfrgov
bull Alaska State Statutes
ndash httpwwwlegisstateakusbasisfolioasp
bull Alaska Administrative Code
ndash Title 7 ndash Health amp Social Services gt Part 8 ndash Medicaid Coverage and Payment
ndash Chapters 105 ndash 160 ndash Medical Assistance
ndash Chapter 48 ndash Chronic and Acute Medical Assistance (CAMA)
ndash httpwwwlegisstateakusbasisfolioasp
6
Federal Oversight
The US Department of Health amp Human Services (HHS) governs all state Medicaid
programs through the Centers for Medicare amp Medicaid Services (CMS)
bull CMS administers federally funded health benefit programs including
ndash Health Insurance Marketplace (aka federal Health Insurance Exchange)
ndash Medicare - Title XVIII of Social Security Act
ndash Medicaid - Title XXI of Social Security Act
ndash Childrenrsquos Health Insurance Program (CHIP)
7
State Oversight
The Alaska Department of Health amp Social Services provides state-level oversight of the
Alaska Medical Assistance program through the following divisions
bull Office of the Commissioner
ndash Office of Rate Review
ndash Office of Program Integrity
bull Division of Public Assistance (DPA)
bull Division of Health Care Services (DHCS)
bull Division of Behavioral Health (DBH)
bull Division of Senior and Disabilities Services (DSDS)
httpdhssalaskagovPagesdefaultaspx
8
Office of the Commissioner
Oversees
bull Divisions of the Department of Health and Social Services
bull Office of Program Integrity
bull Office of Rate Review
httpdhssalaskagovCommissionerPagesdefaultaspx
9
Division of Public Assistance
bull Determines eligibility for most Alaska Medical Assistance programs as well as food
stamps cash assistance childcare and other programs
bull Issues Alaska Medical Assistance couponscards
bull Oversees Women Infant amp Children (WIC) program
httpdhssalaskagovdpaPagesdefaultaspx
10
Division of Health Care Services
Oversees
bull Provider professional facility pharmacy ancillary and other services
bull Tribal Health program
bull Member services
bull Care Management Program (CMP)
bull Systems Maintenance amp Data Analysis Unit
bull Provider second-level appeals and member fair hearings
bull Fiscal Agent oversight (Conduent)
bull Pharmacy contractor (Magellan Medicaid Administration)
bull Utilization management and case management contract oversight (Comagine Health)
bull Vision care contract oversight (Classic Optical)
httpdhssalaskagovdhcsPagesdefaultaspx
11
Division of Behavioral Health
Oversees
bull Outpatient mental health programs inpatient psychiatric care residential psychiatric
services
bull Substance abuse rehabilitation program certification
bull Behavioral Health program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdbhPagesdefaultaspx
12
Division of Senior and Disabilities Services (DSDS)
Oversees
bull Level of care determinations authorization of services and quality assurance for Home amp
Community Based Services (HCBS) Waiver and Personal Care Assistance (PCA)
programs
bull Provider certification for both HCBS and PCA programs
bull All long-term care (LTC) stay authorizations
bull Program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdsdsPagesdefaultaspx
13
Contractors
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
4
Alaska Medical Assistance
Alaska Medical Assistance is comprised of Medicaid Denali KidCare (DKC) and Chronic
and Acute Medical Assistance (CAMA) and provides health coverage to eligible Alaskans
bull The term ldquoAlaska Medicaidrdquo is used to refer to both Alaska Medicaid and DKC
bull The Department of Health and Social Services (DHSS) administers the Alaska
Medical Assistance Program
bull Alaska Medicaid (including DKC) is jointly funded by the federal government and the
State of Alaska
bull A Medicaid fiscal agent is a contractor that processes and pays provider claims
Conduent Health is Alaska Medicaidrsquos fiscal agent
5
Federal and State Regulations
Many federal and state regulations govern the Alaska Medical Assistance program
bull Code of Federal Regulations (CFR)
ndash Title 42 - Public Health
ndash httpwwwecfrgov
bull Alaska State Statutes
ndash httpwwwlegisstateakusbasisfolioasp
bull Alaska Administrative Code
ndash Title 7 ndash Health amp Social Services gt Part 8 ndash Medicaid Coverage and Payment
ndash Chapters 105 ndash 160 ndash Medical Assistance
ndash Chapter 48 ndash Chronic and Acute Medical Assistance (CAMA)
ndash httpwwwlegisstateakusbasisfolioasp
6
Federal Oversight
The US Department of Health amp Human Services (HHS) governs all state Medicaid
programs through the Centers for Medicare amp Medicaid Services (CMS)
bull CMS administers federally funded health benefit programs including
ndash Health Insurance Marketplace (aka federal Health Insurance Exchange)
ndash Medicare - Title XVIII of Social Security Act
ndash Medicaid - Title XXI of Social Security Act
ndash Childrenrsquos Health Insurance Program (CHIP)
7
State Oversight
The Alaska Department of Health amp Social Services provides state-level oversight of the
Alaska Medical Assistance program through the following divisions
bull Office of the Commissioner
ndash Office of Rate Review
ndash Office of Program Integrity
bull Division of Public Assistance (DPA)
bull Division of Health Care Services (DHCS)
bull Division of Behavioral Health (DBH)
bull Division of Senior and Disabilities Services (DSDS)
httpdhssalaskagovPagesdefaultaspx
8
Office of the Commissioner
Oversees
bull Divisions of the Department of Health and Social Services
bull Office of Program Integrity
bull Office of Rate Review
httpdhssalaskagovCommissionerPagesdefaultaspx
9
Division of Public Assistance
bull Determines eligibility for most Alaska Medical Assistance programs as well as food
stamps cash assistance childcare and other programs
bull Issues Alaska Medical Assistance couponscards
bull Oversees Women Infant amp Children (WIC) program
httpdhssalaskagovdpaPagesdefaultaspx
10
Division of Health Care Services
Oversees
bull Provider professional facility pharmacy ancillary and other services
bull Tribal Health program
bull Member services
bull Care Management Program (CMP)
bull Systems Maintenance amp Data Analysis Unit
bull Provider second-level appeals and member fair hearings
bull Fiscal Agent oversight (Conduent)
bull Pharmacy contractor (Magellan Medicaid Administration)
bull Utilization management and case management contract oversight (Comagine Health)
bull Vision care contract oversight (Classic Optical)
httpdhssalaskagovdhcsPagesdefaultaspx
11
Division of Behavioral Health
Oversees
bull Outpatient mental health programs inpatient psychiatric care residential psychiatric
services
bull Substance abuse rehabilitation program certification
bull Behavioral Health program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdbhPagesdefaultaspx
12
Division of Senior and Disabilities Services (DSDS)
Oversees
bull Level of care determinations authorization of services and quality assurance for Home amp
Community Based Services (HCBS) Waiver and Personal Care Assistance (PCA)
programs
bull Provider certification for both HCBS and PCA programs
bull All long-term care (LTC) stay authorizations
bull Program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdsdsPagesdefaultaspx
13
Contractors
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
5
Federal and State Regulations
Many federal and state regulations govern the Alaska Medical Assistance program
bull Code of Federal Regulations (CFR)
ndash Title 42 - Public Health
ndash httpwwwecfrgov
bull Alaska State Statutes
ndash httpwwwlegisstateakusbasisfolioasp
bull Alaska Administrative Code
ndash Title 7 ndash Health amp Social Services gt Part 8 ndash Medicaid Coverage and Payment
ndash Chapters 105 ndash 160 ndash Medical Assistance
ndash Chapter 48 ndash Chronic and Acute Medical Assistance (CAMA)
ndash httpwwwlegisstateakusbasisfolioasp
6
Federal Oversight
The US Department of Health amp Human Services (HHS) governs all state Medicaid
programs through the Centers for Medicare amp Medicaid Services (CMS)
bull CMS administers federally funded health benefit programs including
ndash Health Insurance Marketplace (aka federal Health Insurance Exchange)
ndash Medicare - Title XVIII of Social Security Act
ndash Medicaid - Title XXI of Social Security Act
ndash Childrenrsquos Health Insurance Program (CHIP)
7
State Oversight
The Alaska Department of Health amp Social Services provides state-level oversight of the
Alaska Medical Assistance program through the following divisions
bull Office of the Commissioner
ndash Office of Rate Review
ndash Office of Program Integrity
bull Division of Public Assistance (DPA)
bull Division of Health Care Services (DHCS)
bull Division of Behavioral Health (DBH)
bull Division of Senior and Disabilities Services (DSDS)
httpdhssalaskagovPagesdefaultaspx
8
Office of the Commissioner
Oversees
bull Divisions of the Department of Health and Social Services
bull Office of Program Integrity
bull Office of Rate Review
httpdhssalaskagovCommissionerPagesdefaultaspx
9
Division of Public Assistance
bull Determines eligibility for most Alaska Medical Assistance programs as well as food
stamps cash assistance childcare and other programs
bull Issues Alaska Medical Assistance couponscards
bull Oversees Women Infant amp Children (WIC) program
httpdhssalaskagovdpaPagesdefaultaspx
10
Division of Health Care Services
Oversees
bull Provider professional facility pharmacy ancillary and other services
bull Tribal Health program
bull Member services
bull Care Management Program (CMP)
bull Systems Maintenance amp Data Analysis Unit
bull Provider second-level appeals and member fair hearings
bull Fiscal Agent oversight (Conduent)
bull Pharmacy contractor (Magellan Medicaid Administration)
bull Utilization management and case management contract oversight (Comagine Health)
bull Vision care contract oversight (Classic Optical)
httpdhssalaskagovdhcsPagesdefaultaspx
11
Division of Behavioral Health
Oversees
bull Outpatient mental health programs inpatient psychiatric care residential psychiatric
services
bull Substance abuse rehabilitation program certification
bull Behavioral Health program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdbhPagesdefaultaspx
12
Division of Senior and Disabilities Services (DSDS)
Oversees
bull Level of care determinations authorization of services and quality assurance for Home amp
Community Based Services (HCBS) Waiver and Personal Care Assistance (PCA)
programs
bull Provider certification for both HCBS and PCA programs
bull All long-term care (LTC) stay authorizations
bull Program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdsdsPagesdefaultaspx
13
Contractors
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
6
Federal Oversight
The US Department of Health amp Human Services (HHS) governs all state Medicaid
programs through the Centers for Medicare amp Medicaid Services (CMS)
bull CMS administers federally funded health benefit programs including
ndash Health Insurance Marketplace (aka federal Health Insurance Exchange)
ndash Medicare - Title XVIII of Social Security Act
ndash Medicaid - Title XXI of Social Security Act
ndash Childrenrsquos Health Insurance Program (CHIP)
7
State Oversight
The Alaska Department of Health amp Social Services provides state-level oversight of the
Alaska Medical Assistance program through the following divisions
bull Office of the Commissioner
ndash Office of Rate Review
ndash Office of Program Integrity
bull Division of Public Assistance (DPA)
bull Division of Health Care Services (DHCS)
bull Division of Behavioral Health (DBH)
bull Division of Senior and Disabilities Services (DSDS)
httpdhssalaskagovPagesdefaultaspx
8
Office of the Commissioner
Oversees
bull Divisions of the Department of Health and Social Services
bull Office of Program Integrity
bull Office of Rate Review
httpdhssalaskagovCommissionerPagesdefaultaspx
9
Division of Public Assistance
bull Determines eligibility for most Alaska Medical Assistance programs as well as food
stamps cash assistance childcare and other programs
bull Issues Alaska Medical Assistance couponscards
bull Oversees Women Infant amp Children (WIC) program
httpdhssalaskagovdpaPagesdefaultaspx
10
Division of Health Care Services
Oversees
bull Provider professional facility pharmacy ancillary and other services
bull Tribal Health program
bull Member services
bull Care Management Program (CMP)
bull Systems Maintenance amp Data Analysis Unit
bull Provider second-level appeals and member fair hearings
bull Fiscal Agent oversight (Conduent)
bull Pharmacy contractor (Magellan Medicaid Administration)
bull Utilization management and case management contract oversight (Comagine Health)
bull Vision care contract oversight (Classic Optical)
httpdhssalaskagovdhcsPagesdefaultaspx
11
Division of Behavioral Health
Oversees
bull Outpatient mental health programs inpatient psychiatric care residential psychiatric
services
bull Substance abuse rehabilitation program certification
bull Behavioral Health program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdbhPagesdefaultaspx
12
Division of Senior and Disabilities Services (DSDS)
Oversees
bull Level of care determinations authorization of services and quality assurance for Home amp
Community Based Services (HCBS) Waiver and Personal Care Assistance (PCA)
programs
bull Provider certification for both HCBS and PCA programs
bull All long-term care (LTC) stay authorizations
bull Program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdsdsPagesdefaultaspx
13
Contractors
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
7
State Oversight
The Alaska Department of Health amp Social Services provides state-level oversight of the
Alaska Medical Assistance program through the following divisions
bull Office of the Commissioner
ndash Office of Rate Review
ndash Office of Program Integrity
bull Division of Public Assistance (DPA)
bull Division of Health Care Services (DHCS)
bull Division of Behavioral Health (DBH)
bull Division of Senior and Disabilities Services (DSDS)
httpdhssalaskagovPagesdefaultaspx
8
Office of the Commissioner
Oversees
bull Divisions of the Department of Health and Social Services
bull Office of Program Integrity
bull Office of Rate Review
httpdhssalaskagovCommissionerPagesdefaultaspx
9
Division of Public Assistance
bull Determines eligibility for most Alaska Medical Assistance programs as well as food
stamps cash assistance childcare and other programs
bull Issues Alaska Medical Assistance couponscards
bull Oversees Women Infant amp Children (WIC) program
httpdhssalaskagovdpaPagesdefaultaspx
10
Division of Health Care Services
Oversees
bull Provider professional facility pharmacy ancillary and other services
bull Tribal Health program
bull Member services
bull Care Management Program (CMP)
bull Systems Maintenance amp Data Analysis Unit
bull Provider second-level appeals and member fair hearings
bull Fiscal Agent oversight (Conduent)
bull Pharmacy contractor (Magellan Medicaid Administration)
bull Utilization management and case management contract oversight (Comagine Health)
bull Vision care contract oversight (Classic Optical)
httpdhssalaskagovdhcsPagesdefaultaspx
11
Division of Behavioral Health
Oversees
bull Outpatient mental health programs inpatient psychiatric care residential psychiatric
services
bull Substance abuse rehabilitation program certification
bull Behavioral Health program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdbhPagesdefaultaspx
12
Division of Senior and Disabilities Services (DSDS)
Oversees
bull Level of care determinations authorization of services and quality assurance for Home amp
Community Based Services (HCBS) Waiver and Personal Care Assistance (PCA)
programs
bull Provider certification for both HCBS and PCA programs
bull All long-term care (LTC) stay authorizations
bull Program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdsdsPagesdefaultaspx
13
Contractors
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
8
Office of the Commissioner
Oversees
bull Divisions of the Department of Health and Social Services
bull Office of Program Integrity
bull Office of Rate Review
httpdhssalaskagovCommissionerPagesdefaultaspx
9
Division of Public Assistance
bull Determines eligibility for most Alaska Medical Assistance programs as well as food
stamps cash assistance childcare and other programs
bull Issues Alaska Medical Assistance couponscards
bull Oversees Women Infant amp Children (WIC) program
httpdhssalaskagovdpaPagesdefaultaspx
10
Division of Health Care Services
Oversees
bull Provider professional facility pharmacy ancillary and other services
bull Tribal Health program
bull Member services
bull Care Management Program (CMP)
bull Systems Maintenance amp Data Analysis Unit
bull Provider second-level appeals and member fair hearings
bull Fiscal Agent oversight (Conduent)
bull Pharmacy contractor (Magellan Medicaid Administration)
bull Utilization management and case management contract oversight (Comagine Health)
bull Vision care contract oversight (Classic Optical)
httpdhssalaskagovdhcsPagesdefaultaspx
11
Division of Behavioral Health
Oversees
bull Outpatient mental health programs inpatient psychiatric care residential psychiatric
services
bull Substance abuse rehabilitation program certification
bull Behavioral Health program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdbhPagesdefaultaspx
12
Division of Senior and Disabilities Services (DSDS)
Oversees
bull Level of care determinations authorization of services and quality assurance for Home amp
Community Based Services (HCBS) Waiver and Personal Care Assistance (PCA)
programs
bull Provider certification for both HCBS and PCA programs
bull All long-term care (LTC) stay authorizations
bull Program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdsdsPagesdefaultaspx
13
Contractors
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
9
Division of Public Assistance
bull Determines eligibility for most Alaska Medical Assistance programs as well as food
stamps cash assistance childcare and other programs
bull Issues Alaska Medical Assistance couponscards
bull Oversees Women Infant amp Children (WIC) program
httpdhssalaskagovdpaPagesdefaultaspx
10
Division of Health Care Services
Oversees
bull Provider professional facility pharmacy ancillary and other services
bull Tribal Health program
bull Member services
bull Care Management Program (CMP)
bull Systems Maintenance amp Data Analysis Unit
bull Provider second-level appeals and member fair hearings
bull Fiscal Agent oversight (Conduent)
bull Pharmacy contractor (Magellan Medicaid Administration)
bull Utilization management and case management contract oversight (Comagine Health)
bull Vision care contract oversight (Classic Optical)
httpdhssalaskagovdhcsPagesdefaultaspx
11
Division of Behavioral Health
Oversees
bull Outpatient mental health programs inpatient psychiatric care residential psychiatric
services
bull Substance abuse rehabilitation program certification
bull Behavioral Health program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdbhPagesdefaultaspx
12
Division of Senior and Disabilities Services (DSDS)
Oversees
bull Level of care determinations authorization of services and quality assurance for Home amp
Community Based Services (HCBS) Waiver and Personal Care Assistance (PCA)
programs
bull Provider certification for both HCBS and PCA programs
bull All long-term care (LTC) stay authorizations
bull Program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdsdsPagesdefaultaspx
13
Contractors
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
10
Division of Health Care Services
Oversees
bull Provider professional facility pharmacy ancillary and other services
bull Tribal Health program
bull Member services
bull Care Management Program (CMP)
bull Systems Maintenance amp Data Analysis Unit
bull Provider second-level appeals and member fair hearings
bull Fiscal Agent oversight (Conduent)
bull Pharmacy contractor (Magellan Medicaid Administration)
bull Utilization management and case management contract oversight (Comagine Health)
bull Vision care contract oversight (Classic Optical)
httpdhssalaskagovdhcsPagesdefaultaspx
11
Division of Behavioral Health
Oversees
bull Outpatient mental health programs inpatient psychiatric care residential psychiatric
services
bull Substance abuse rehabilitation program certification
bull Behavioral Health program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdbhPagesdefaultaspx
12
Division of Senior and Disabilities Services (DSDS)
Oversees
bull Level of care determinations authorization of services and quality assurance for Home amp
Community Based Services (HCBS) Waiver and Personal Care Assistance (PCA)
programs
bull Provider certification for both HCBS and PCA programs
bull All long-term care (LTC) stay authorizations
bull Program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdsdsPagesdefaultaspx
13
Contractors
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
11
Division of Behavioral Health
Oversees
bull Outpatient mental health programs inpatient psychiatric care residential psychiatric
services
bull Substance abuse rehabilitation program certification
bull Behavioral Health program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdbhPagesdefaultaspx
12
Division of Senior and Disabilities Services (DSDS)
Oversees
bull Level of care determinations authorization of services and quality assurance for Home amp
Community Based Services (HCBS) Waiver and Personal Care Assistance (PCA)
programs
bull Provider certification for both HCBS and PCA programs
bull All long-term care (LTC) stay authorizations
bull Program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdsdsPagesdefaultaspx
13
Contractors
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
12
Division of Senior and Disabilities Services (DSDS)
Oversees
bull Level of care determinations authorization of services and quality assurance for Home amp
Community Based Services (HCBS) Waiver and Personal Care Assistance (PCA)
programs
bull Provider certification for both HCBS and PCA programs
bull All long-term care (LTC) stay authorizations
bull Program grant administration
bull Technical support for clinical issues
httpdhssalaskagovdsdsPagesdefaultaspx
13
Contractors
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
13
Contractors
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
14
Conduent
Conduent is the fiscal agent for Alaska Medical Assistance program
bull Enrolls providers
bull Operates the Provider Inquiry and Member Services call centers
bull Approves many service authorization types
bull Processes claims
bull Drafts and publishes most provider billing manuals newsletters and other provider
communications
bull Creates and delivers Alaska Medical Assistance provider training
bull Performs first-level appeals for denied claims and service authorizations denied by
Conduent
bull Operates the Alaska Medical Assistance Fraud and Abuse Hotline
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
15
Comagine Health
Comagine Health administers most of the utilization management aspects of the Alaska
Medical Assistance program
bull Provides member case management services
bull Performs utilization reviewservice authorization for
ndash Residential and inpatient psychiatric treatment
ndash Select inpatient and outpatient diagnoses and procedures
ndash All acute care inpatient stays longer than 3 days
ndash Outpatient imaging
bull Quality of care reviews or assessments
bull Performs TEFRA application reviews
bull Reviews first-level appeals for service authorization requests denied by Comagine
bull Educates providers on care management and related services
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
16
Optum
Optum is the Administrative Services Organization (ASO) for the Division of Behavioral
Health They are responsible for
bull Processing and payment of specified behavioral health claims
bull Provider inquiry problem resolution and first level appeals
bull Service authorization for specified outpatient behavioral health providers
bull Provider communication and outreach
bull Provider training and billing manuals
bull Participant eligibility verification and assistance
bull Providers included are
ndash 1115 waiver provider services as of 2152020
ndash Independent Psychologists as of 4242020
ndash Autism services providers as of 712020
ndash Community Behavioral Health service providers as of 712020
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
17
Magellan Medicaid Administration
Magellan Medicaid Administration is responsible for administering the Pharmacy Benefits
program for Alaska Medical Assistance
bull Utilizes member eligibility established by Division of Public Assistance
bull Adjudicates claims based on pharmacy benefit plan rules set by the State including
covered drugs prior authorization quantity limits early refills third-party liability (TPL) etc
bull Sends real-time Prospective Drug Utilization Review (ProDUR) messages to the pharmacy
during electronic point-of-sale claims adjudication
bull Operates the Pharmacy Clinical and Technical call centers
bull Processes pharmacy service authorizations via electronic Prior Authorizations (ePA) using
the CoverMy Meds platform and via fax
bull Drug Utilization Review contractor (prospective and retrospective)
bull Rebate contractor
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
18
Classic Optical
Classic Optical is the Alaska Medicaid contractor for lenses and glasses frames
bull All Alaska Medical Assistance prescribed eyewear must be ordered from this contractor
Contact Lens Services
Alaska Medical Assistance pays for contact lenses under limited circumstances Prior authorization is
required Providers receiving prior authorization must present a quote from a contact provider of choice to the
department for final approval prior to ordering the lenses (Classic Optical does not manage contact lens services)
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
19
Providers
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
20
Provider Enrollment Process
The Alaska Medical Assistance enrollment process begins with the provider enrollment portal
on Health Enterprise
bull httpmedicaidalaskacom Provider Enrollment
bull Prospective providers will need to complete the online application process
bull Once the application is complete any supporting documentation appropriate signature
pages and applicable enrollment fees necessary for the requested provider type must be
mailed with original signatures to
Conduent
Provider Enrollment
PO Box 240808
Anchorage AK 99524-0808
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
21
Provider Enrollment Process
bull All providers must re-enroll periodically every 3 to 5 years depending on the provider type
bull In addition to enrolling providers must be correctly affiliated with their billing organizations and
groups where applicable
bull Enrollment requirements for specific provider types are available in applicable provider-specific
billing manuals
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
22
Provider Information Updates
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
23
Recordkeeping
bull Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
bull Although most recordkeeping requirements are consistent for all providers some
requirements are provider-type specific
bull Providers must maintain complete and accurate clinical financial and other relevant
records to support the care and services for which they bill Alaska Medical Assistance
for a minimum of 7 years from the date of service
bull Providers are subject to audits reviews and investigations
Providers must ensure their staff billing agents and any other entities responsible
for any aspect of records maintenance meet the same requirements
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
24
Members
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
25
Member Eligibility
Services are only covered if they are rendered to an individual that is eligible to receive
Alaska Medical Assistance coverage
bull Provider billing manuals include the member eligibility code(s) that may be authorized to
receive the services by the specified provider type if all other requirements are met
bull Eligibility periods and coverage limits vary
ndash Denali KidCare participants have 12 months of continuous eligibility
ndash Most adult eligibility is determined a month at a time
ndash Some eligibility types have shorter eligibility periods and limited coverage
ndash Additional information on member eligibility or covered services may be found in the
Alaska Medicaid Recipient Handbook at
httpdhssalaskagovdhcsDocumentsPDFRecipient-Handbookpdf
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
26
Member Eligibility
Alaska Medical Assistance will only reimburse services provided to an individual eligible to
receive those benefits for the current month
bull Must verify identity of the Member
bull Verify member eligibility for the current month
ndash Review and photocopy the Member Eligibility Card or Coupon
ndash Check Member Eligibility option in Health Enterprise
ndash Call the Automated Voice Response System at 8553298986
ndash Call Provider Inquiry at 9076446800 opt 12 or 8007705650 opt 11 2
bull Benefit month reads as MMYY or MMDDYYYY depending on source
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
27
Member Eligibility Cards amp Coupons
1 Member Name 4 Eligibility Code
2 Member ID 5 Eligibility MonthYear
3 Date of Birth 6 Resource Code
1 2
1
1
1
2
2
2
3
3
3
3 4
4
4
4 5 5
5 5
6
6 6
6
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
28
Member Cost-Sharing
A cost-share is an established ldquodeductiblerdquo amount the member is responsible for paying on
certain services
bull Services may not be denied because of a memberrsquos inability to pay at the time of service
bull DHSS will reduce payment to the provider by the memberrsquos cost-sharing amount
bull Cost sharing amounts are as follows
ndash $50 per day up to a maximum of $200 per discharge for inpatient hospital services
ndash 5 of allowable charges for outpatient hospital services
ndash $3 per day for physician services
bull For prescription drugs filled or refilled
ndash $050 for each prescription drug $50 or less
ndash $350 for each prescription drug more than $50
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
29
Services Not Subject to Cost-Sharing
bull Services provided to member under age 18 at the time of service
bull Services provided at a long-term care facility or an intermediate care facility
bull Services provided to a pregnant woman including the postpartum period
bull Family planning services and supplies
bull Emergency services
bull IHS beneficiaries receiving services at IHS facilities including IHS beneficiaries referred or
transferred to a non-IHS facility
bull Hospice services
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
30
Resources
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
31
Billing Manuals
Billing manuals are available at httpmanualsmedicaidalaskacom
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
32
Billing Manual Structures
Most provider billing manuals are arranged in one of two ways depending on the topic
Service Category ndash applies to various provider types rendering like services such as EPSDT
bull Section I ndash service specific information
bull Section II ndash claims management information
bull Section III ndash general program information
Provider Type ndash depicts services and requirements for a specific provider type such as Dental
bull Section I ndash provider-type specific information
bull Section II ndash claims management information
bull Section III ndash general program information
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
33
Billing Manual Example
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
34
Fee Schedules
Fee schedules can be found on httpmedicaidalaskacom on the Fee Schedule page
Fee schedules tell you
bull What services are covered
bull Maximum allowed reimbursement
bull Additional documentation requirements
bull Other special considerations
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
35
Fee Schedule Example
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
36
Behavioral Health Fee Schedules Both Community Behavioral Health and Mental Health Physician Clinic fee schedules are available at
httpdhssalaskagovdbhPagesResourcesMedicaidrelatedaspx
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
37
PCA amp Waiver Service Fee Schedule
The PCA amp Waiver Services fee schedule is available at
httpdhssalaskagovdsdsPagesinfocostsurveyaspx
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
38
Newsletter
Newsletters can be found on wwwmedicaidalaskacom under Documentationgt Newsletters
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
39
RA Messages
RA Messages can be found on wwwmedicaidalaskacom on the RA Message page
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
40
RA Messages bull You will find RA messages on page 2 of your Remittance Advice as well as on the RA message page
on wwwmedicaidalaskacom
bull RA messages are Alaska Medicaidrsquos official mode of communication with providers
bull Providers are responsible for knowing and complying with information shared in RA messages
bull RA messages communicate information such as
‒ Proposed and adopted regulations
‒ Public hearings
‒ Changes in billing procedures or policy
‒ Documentation requirements
‒ Changes in covered andor allowable codes
‒ Provider training schedules
‒ Office closures
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
41
Provider Updates
Provider Updates can be found on wwwmedicaidalaskacom under Documentationgt Documents
and FormsgtProvider Updates
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
42
Services
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
43
Covered Services
Alaska Medical Assistance will reimburse actively enrolled providers for medically necessary
covered services if rendered
bull by qualified personnel as described in program rules
bull in compliance with applicable program rules regulations and statutes
bull to eligible Alaska Medical Assistance Members
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
44
Covered Services (cont)
bull Before rendering services verify that the service(s) being provided is covered
ndash for the member based on their eligibility code and age along with any service
limitations
ndash for the provider type rendering the service based on the providerrsquos enrolled credentials
bull Covered services are listed in provider billing manuals andor within separately published
fee schedules
bull Age andor service restrictions may apply
bull Service authorization requirements may apply
bull Medical justification or consent form documentation may be required
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
45
Transportation Services
Alaska Medical Assistance covers out-of-area transportation and accommodation services and
some local transportation services when travel is needed to receive medically necessary
services
bull Service authorization is required for all non-emergent transportation and accommodation
services and must be obtained prior to travel
bull Out-of-area travel is available when
ndash Medically necessary services are not available in the memberrsquos community within three
months of need
ndash The total cost of out-of-area medical transportation and accommodation services is less
than the cost of local services or
ndash The member is an IHS beneficiary who has requested services from the nearest IHS
services or tribal facility
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
46
Telemedicine Some services may be provided via telemedicine
bull In order for Alaska Medicaid to cover telemedicine services the services must be
ndash Covered by Alaska Medicaid
ndash Provided by an Alaska Medicaid enrolled provider within the scope of their license or
certification
ndash Rendered to a member eligible to receive those services
ndash Appropriate for telemedicine delivery
ndash Performed using a specified delivery method
bull Covered telemedicine services are limited to
ndash An initial visit
ndash One follow-up visit
ndash A consultation to confirm a diagnosis
ndash Diagnostic therapeutic or interpretive services
ndash A psychiatric or substance abuse assessment
ndash Psychotherapy
ndash Pharmacological management services on a individual member basis
Methods of delivery
bull Interactive (Live) ndash provided
through real-time camera video or
dedicated audio conference
equipment
bull Store and forward ndash performed
using the transference of digital
images sounds or previously
recorded video from one location to
another allowing the consulting
provider to obtain information
analyze it and report back to the
referring provider
bull Self-monitoring ndash provided using a
telemedicine application based
directly in the memberrsquos home and
with only indirect involvement from
the provider to perform the service
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
47
Service Authorizations
A service authorization (SA) may be required to receive reimbursement
bull When possible required SAs must be obtained prior to rendering services
bull Different entities are responsible for authorizing services
ndash Comagine
ndash Conduent
ndash Division of Senior and Disability Services
ndash Division of Behavioral Health
ndash Magellan
ndash Optum
bull SA numbers must be documented in the appropriate field on each claim form
Review the appropriate fee schedule and billing
manual to determine if a service requires an SA
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
48
Non-Covered Medicaid Services
For more comprehensive information about services that are not covered by AK Medical
Assistance refer to 7 AAC 105 ndash 7AAC 160 and the provider billing manual specific to your
provider type The following list over the new few slides includes many of the services that
are not covered
bull A service that is not medically necessary and not reasonably necessary for the diagnosis
and treatment of an illness or injury or for the correction of an organic system or not
identified in an EPSDT screening (refer to 7 AAC 110205)
bull A service that is provided outside the scope of the providerrsquos licensure or not properly
prescribed
bull Advance nurse practitioner serving as a primary surgeon
bull Alternative therapy or other service including acupuncture homeopathic or naturopathic
remedy and Ayurvedic medicine
bull Case management services
bull Chiropractic manipulation for recipients age 21 and older unless the recipient is also a
Medicare Part B beneficiary
bull Double-occupancy rates for hotel rooms
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
49
Non-Covered Medicaid Services (cont)
bull Brand-name drugs if a therapeutically equivalent generic drug is on the market
‒ Excepting brand name drugs included on the Alaska Medicaid Preferred Drug List
(PDL)
‒ Excepting instances where the prescriber indicates brand-name medically necessary
bull Drugs for which more than a 30-day supply is ordered per prescription
‒ Excepting birth control drugs and drugs listed on the Alaska Medicaid PDL if dispensed
in an unopened container
bull Drugs used for the symptomatic relief of coughs and colds
bull Drugs used to treat infertility obesity or baldness
bull Drugs that are prohibited from receiving federal Medicaid matching funds (refer to 42 CFR
44125)
bull Educational services and supplies
bull Experimental or investigative services
bull Gender reassignment procedures or sequelae
bull Hysterectomies performed for sterilization purposes only
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
50
Non-Covered Medicaid Services (cont)
bull Impotence treatment or services
bull Infertility services
bull Interpreter services
bull Maintenance therapy
bull Medical testimony
bull No-show or cancelled appointments
bull Non-prescription drug vitamin or dietary or herbal supplements unless otherwise
indicated in 7 AAC 120110(a)(4)
bull Office supplies
bull Operating room assistance provided by an intern registered nurse or licensed practical
nurse
bull Plastic or cosmetic services for enhancement purposes hair or wrinkle removal
bull Podiatry services for members age 21 and older unless the member is also a Medicare
part B beneficiary
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
51
Non-Covered Medicaid Services (cont)
bull Programs to improve overall fitness
bull Selected special services and report codes
bull Services billed using non-covered CPT or HCPCS codes
bull Special reports
bull Sterilization for recipients institutionalized in psychiatric facilities for recipients who are
under 21 years of age or for recipients determined by a court to be incompetent
bull Surgical Trays
bull Swimming therapy
bull Travel by the provider
bull Vaccine products that are available for free
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
52
Billing
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
53
Rate Methodologies
Alaska Medicaid reimburses in-state providers at the lesser of
bull The providerrsquos billed charges
bull The providerrsquos lowest charge advertised quoted posted billed or discounted for any other person or patient at
the same time with some exceptions
bull The rate methodology identified for the specific provider type Common rate methodologies and the provider
types to which they apply include
ndash Resource-Based Relative Value System (RBRVS)
bull Physicians and mid-level practitioners such as advance practice registered nurses or direct-entry midwives
ndash Prospective cost-based rate system
bull Hospitals or ambulatory surgery centers
ndash Encounter rate
bull Federally Qualified Health Centers Rural Health Clinics or Tribal Health Clinics
ndash Centers for Medicare and Medicaid Services (CMS) ndash established rates
bull Hospices or laboratories
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
54
Claims Intake
Submission Method
Claims are submitted using various methods
Claim Format
bull Paper forms
bull Electronic submission
‒ Health Enterprise
‒ Practice Management Software
‒ Payerpath
‒ Clearinghouse
‒ Crossover Claims via Medicare
bull Point-of-Sale transactions for pharmacy providers
bull Professional Claim Form
‒ CMS-1500
‒ 837P
bull Institutional Claim Form
‒ UB-04
‒ 837I
bull Dental Claim Form
‒ J430
‒ 837D
bull Transportation Accommodation ndash AK-04
‒ effective 06272020 transportation claims must
be submitted via CMS-1500 or 837P
bull AdjustmentVoid Request Form
‒ AK-05
‒ Replacement claim
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
55
Electronic Billing Requirements
Providers electing to submit claims electronically using practice management software must
complete a HIPAA certification process
Documentation Requirements
bull Available at httpsmedicaidalaskacom Documentation Documents amp Forms
Forms
ndash Provider or Billing Agent Information Submission Agreement commonly referred to as a
PISA or BAISA Enrollment Forms
ndash Electronic Remittance (835) Authorization election where provider designates who
receives the 835 transaction which is the weekly claim transactionprocessing summary
Transaction Testing Requirements
bull Review applicable companion guide(s) for complete testing procedures
httpmanualsmedicaidalaskacomdocscompanionguideshtm
bull For further assistance the accompanying Technical Report Type 3 (TR3) is available for
purchase through the Washington Publishing Company at httpwwwwpc-edicom
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
56
Alaska Medicaid Health Enterprise
Providers may submit claims through Health Enterprise
bull Must be enrolled with AK Medicaid and have an account on the portal
bull Accessed through wwwmedicaidalaskacom
bull For a more detailed information consider attending the claims management training
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
57
Payerpath
Payerpath is a web-based electronic transaction program provided by the State of Alaska
free of charge
bull Claims submission is via the internet
bull Processing is immediate
bull Pre-submission claim auditing allows error correction prior to claim submission
bull Allows providers to save member demographics for more efficient future billing
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
58
Medicare Crossover Claims
bull Providers are required to bill Medicare prior to Medicaid for members who have both
Medicare and Medicaid eligibility
bull Claims that are electronically submitted to Medicare should automatically ldquocross overrdquo from
Medicarersquos system to Health Enterprise
bull If crossover claims do not appear on the Remittance Advice from Alaska Medical
Assistance within one month of receiving the Explanation of Medicare Benefits (EOMB)
from Medicare providers may contact Provider Inquiry to verify the claim status
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
59
Attachments
bull Some claims will need supporting documentation included with the claim such as
ndash Explanation of Benefits from other insurance
ndash Medical records or clinical documentation
ndash Consent forms
bull When billing using paper claim forms attachments must be sent in along with the claim
bull When billing electronically attachments must be faxed in the same day the claim is
submitted
bull For electronic billing an attachment control number must be
ndash Entered into the electronic claim
ndash Written on the attachment(s)
ndash Documented on the fax attachment cover sheet
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
60
Attachment Fax Cover Sheet
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
61
Timely Filing
bull All claims must be filed within 12 months of the date you provided services to the member
bull The 12-month timely filing limit applies to all claims including those that must first be filed
with a third-party carrier
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
62
Third-Party Liability (TPL)
bull Third-party liability is when a resource such as an entity individual or program is or may
be liable to pay all or part of a members medical care for which Alaska Medicaid coverage
is sought
bull The department will pay for a covered service prescription drug or supply only after the
provider has made full use of any other third-party resources available
bull Before Alaska Medicaid will pay a claim all payment amounts and or denials received from
third party sources should be included on the claim and evidence of all payments must be
attached to the claim
bull Claims that must be processed by one or more third-party resources are still subject to a
12-month timely filing requirement
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
63
TPL Exceptions
Alaska Medicaid is the payer of last resort with few exceptions
bull Health care available to American Indians Alaska Natives and other beneficiaries of the
United States Department of Health and Human Services Indian Health Service whether
provided by the Indian Health Service or through tribal organizations funded in whole or in
part by the Indian Health Service is not a third-party resource and may be billed after
Medicaid
bull Services that have been granted a Federal TPL Waiver are exempt from TPL billing
requirements
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
64
Federal TPL Waiver
AK Medical Assistance has been granted a federal TPL waiver for providers that offer
specific categories of service
bull Transportation and accommodation services (except Air Ambulance and Ground
Ambulance services)
bull Home and Community Based Waiver provider services
bull Personal Care Assistant services
bull EPSDT screening services
bull Prenatal Care services
bull Preventive Pediatric services
bull Eye wear (lensesframes ndash only applies to the contract supplier of eyewear)
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
65
Federal TPL Waiver
For those that provide a federal TPL waivered service
bull Providers may but are not required to bill TPL resources before billing Alaska Medicaid
bull The provider may elect to bill the TPL resource when
ndash The service is covered by the TPL resource
ndash The TPL resource payment exceeds expected Alaska Medicaid reimbursement
bull If TPL is billed any TPL reimbursement is compared to the Alaska Medicaid maximum
allowable amount
If the amount on the TPL EOB exceeds the Alaska Medicaid
allowed amount no additional amount will be paid
If the amount on the TPL EOB is less than the Alaska Medicaid
allowed amount the provider will be paid the difference
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
66
Remittance Advice
Remittance Advice (RA) is a weekly statement produced for providers detailing the submitted
charges as paid denied or suspended
bull RAs can be received in a number of ways
ndash Enterprise inbox
ndash Electronic RA (835 transaction) returned to practice management software
ndash Paper RA mailed to the provider
bull Exception codes will appear throughout the RA to explain how the claims processed
ndash Reduced payment
ndash Denied claims
ndash In-process claims awaiting further review by the processor or the state
bull Reconciling your RA with submitted claims is necessary to keep accurate records and
avoid duplicate billing denials
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
67
Adjustments amp Voids
Adjustments and voids are methods providers can use to correct or reverse previously paid
claims
bull Adjustments are used when a claim has paid but minor corrections or adjustments need to
be made For example when
ndash A procedure code charges or number of days billed needs correcting
ndash A third party resource paysrecoups reimbursement for the claim
ndash An update to service authorization (SA) occurs
bull Providers must request to void a claim submitted with incorrect information including
ndash Wrong Member ID number
ndash Wrong Medicaid Contract ID number
ndash Services not rendered
bull Adjustments and voids appear in the RA
bull Records of adjusted and voided claims must be maintained with other financial records
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
68
Overpayments amp Repayment of Payment Errors
Providers should closely review each remittance advice (RA) to ensure it reflects accurate
payment for all billed services including correct member details and services provided
bull In accordance with 7 AAC 105220(e) Alaska Medical Assistance providers have 30 days
from the time of payment to notify the department in writing of a payment error
bull Federal law (42 USC 1320(d)) requires repayment of overpayments to the department
within 60 days of identifying the overpayment
bull Mail the written overpayment notification and a copy of the RA page detailing the
overpayment to the address below
Conduent State Healthcare LLC
PO Box 240807
Anchorage Alaska 99524-0807
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
69
Provider Self-Audits
bull All enrolled providers who submit claims to AK Medicaid during a calendar year must conduct
a review of a statistically valid random sample of submitted claims once every two years
bull If any deficiencies are identified during the self-review the provider must establish appropriate
corrective actions to address all issues found
bull If a provider identifies overpayments through a self-review or at any other time the provider
must report each overpayment to DHSS Office of the Commissioner Medicaid Program
Integrity within 10 business days
bull For more information on the self-audit requirement
‒ See the Medicaid Program Integrity webpage at
httpdhssalaskagovCommissionerPagesProgramIntegritydefaultaspx
ndash See your provider billing manual
ndash Consider attending our Guidelines for Recordkeeping provider training
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
70
Appeals
An appeal is the process providers may use to challenge a decision made by an Alaska
Medical Assistance contractor or the State of Alaska
bull For example a provider might appeal a
ndash Denied or reduced service authorization
ndash Denied or reduced claim
bull There are 2 levels of appeals ndash not all decisions can be appealed to both levels
bull The Appeal Process Information document outlines the appeals process authorities and
timelines
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
71
Additional Resources
Alaska Medicaid Health Enterprise website at httpmedicaidalaskacom
bull Information necessary for successful billing
bull Includes provider-specific Medicaid billing manuals and fee schedules
You may also call
bull Provider Inquiry
ndash Eligibility only ndash 9076446800 option 12 or 8007705650 (toll-free) option 112
ndash Claim status and other inquiries ndash 9076446800 option 11 or 8007705650 (toll-free)
option 111
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
72
Disclaimer
The information contained in this presentation was current at the time it was written It was
prepared as a tool to assist providers and is not intended to be all inclusive grant rights
impose obligations or function as a stand-alone document Although every reasonable effort
has been made to assure the accuracy of the information within the presentation the
ultimate responsibility for the maintenance of records lies with the provider of services
The State of Alaska ndash Department of Health and Social Services ndash and Conduent
Incorporated employees and staff make no representation warranty or guarantee that this
compilation of information is error-free andor comprehensive and will bear no responsibility
or liability for the results or consequences of the use of this guide
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
copy 2016 Conduent Business Services LLC All rights reserved Conduenttrade and Conduent Designtrade are trademarks of Conduent Business Services LLC in the United States andor other countries
