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(a) The division will be responsible for payment for service rendered to a recipient only when the patient was eligible for Medicaid coverage and when the service was properly authorized by the division if it was a service which requires prior authorization.
(b) The fees and rates established by the division, less the amount of cost-sharing required under 7 AAC 43.052, constitute full payment from the division for approved medical care and services provided to recipients.
(c) A provider must bill the fiscal intermediary under contract with the division within 12 months after the date of service except as provided in this subsection. The 12-month deadline for billing is extended only if the provider had reason to believe that the recipient was ineligible at the time service was rendered, the recipient is subsequently determined eligible by a court or administrative hearing authority, and the claim is filed within 12 months after the date of the court or administrative hearing authority's decision that the recipient was eligible. The recipient's failure to notify the provider of a court or administrative hearing authority's decision is not good cause under 7 AAC 43.085(a) for failure to file a claim.
(d) Except as specified in (e) of this section, when a provider furnishes a covered service to a recipient who, before receiving the service, has furnished the provider with a medical assistance coupon or displayed an identification card, the recipient is under no obligation to pay the provider for the service other than the cost-sharing amounts required under 7 AAC 43.052. However, a recipient is liable for the full cost of the service rendered if the recipient fails to furnish evidence of eligibility before receiving the service.
(e) Medicaid eligibility may be determined on a retroactive basis under 7 AAC 43.020. The provider is under no obligation to bill the division for a covered service furnished to an individual found to have retroactive Medicaid eligibility. When a recipient is found to have retroactive eligibility during a month in which a covered service was furnished by a provider, the recipient remains liable for the cost of the service rendered until the provider has been furnished evidence of eligibility and the provider has agreed to accept payment under 7 AAC 43.040 by billing the division for the service. Payments made by a recipient to the provider before retroactive eligibility has been determined by the division must be handled according to 7 AAC 43.060.
(f) Instructions governing the provision of service to Medicaid recipients, including the methods for receiving prior authorization by the division, are contained in the division's provider manuals.
History: Eff. 8/18/79, Register 71; am 11/6/86, Register 100; am 10/15/94, Register 132; am 11/29/97, Register 144; am 3/3/2001, Register 157
Authority: AS 44.77.015
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Last modified 7/05/2006