Section 7 AAC 105.270 - First-level provider appeal(a) A provider may request a first-level appeal of a denied or reduced claim or service under this section if no later than 180 days after the date on the remittance advice for the claim, a provider submits to the department's designee (1) a written request for a first-level appeal of the denied or reduced claim or service that specifies the basis upon which the decision is challenged and includes any supporting documentation;(2) a copy of the original denied or reduced claim and attachments;(3) a copy of the remittance advice relating to the denied or reduced claim; and(4) if applicable, an adjustment or void request completed by the provider correcting the information submitted with the original claim.(b) In an appeal under (a) of this section of a decision that denied the payment of a claim based on the provider's failure to file the claim before the billing deadline under 7 AAC 145.005(c), the department's designee shall(1) approve the appeal and pay the maximum amount allowed under 7 AAC 105 - 7 AAC 160 if the department's designee determines that (A) the department committed an error on a claim previously submitted by the provider for the same service to the same recipient on the same day;(B) the claim was timely filed but not processed; or(C) the provider has good cause under 7 AAC 105.280(h) for the provider's failure to submit the claim before the billing deadline under 7 AAC 145.005(c); or(2) deny the provider's appeal if the department's designee determines that the claim was not timely filed.(c) A provider may request a first-level appeal of a noncertification of hospital admission or length of stay that, under 7 AAC 105 - 7 AAC 160, requires prior approval by a quality improvement organization, if no later than 180 days after the date of the noncertification of the hospital admission or length of stay notice, a provider submits to the quality improvement organization (1) a written request for a first-level appeal that specifies the basis upon which the decision is challenged and includes any supporting documentation;(2) a complete copy of the recipient's medical records that support the hospital admission or length of stay and any other supporting documentation; and(3) a copy of the original noncertification notice and attachments.(d) A provider may request a first-level appeal of a decision that denied or reduced prior authorization under 7 AAC 105 - 7 AAC 160 if, no later than 180 days after the date of that decision, the provider submits a written request for a first-level appeal to the department's designee. This subsection does not include prior authorizations for services that require certification by a quality improvement organization. The appeal must(1) specify the basis upon which the decision is challenged and include any supporting documentation; and(2) include a copy of the original notice of denial of or reduced prior authorization.(e) A provider may request a first-level appeal of a noncertification decision regarding a service that, under 7 AAC 105 - 7 AAC 160, requires certification by a quality improvement organization in order to obtain prior authorization. The provider must submit the appeal to the quality improvement organization no later than 180 days after the date of the noncertification decision. The request for a first-level appeal must be in writing and include(1) the basis upon which the decision is challenged and any supporting documentation; and(2) a copy of the original noncertification notice and attachments.(f) A provider may request a first-level appeal of a recoupment of overpayment notice issued under 7 AAC 105.260(c). The provider must submit the appeal to the department's designee no later than 60 days after the date of the notice and include (1) a written request for an appeal that specifies the basis upon which the notice for recoupment of overpayment is challenged and any supporting documentation; and(2) a copy of the recoupment notice under 7 AAC 105.260(c).(g) Except as provided in (l) of this section, a provider that has been denied enrollment by the department or that is disenrolled from Medicaid for a reason other than a reason in 7 AAC 105.400 may appeal the denial or disenrollment under this subsection by submitting (1) a written request that specifies the basis upon which the decision is challenged and includes any supporting documentation; and(2) a copy of the original denial of enrollment or notice of disenrollment.(h) A provider making an appeal under (g) of section must submit the appeal no later than 180 days after the date of the decision to deny enrollment or to disenroll the provider to the department at the address listed in the department's Addresses for Second Level Provider Appeals list, adopted by reference in 7 AAC 160.900. A decision on appeal under (g) of this section is a final administrative decision, and the department will notify the provider of the provider's right to appeal to the superior court under the Alaska Rules of Appellate Procedure.(i) The department or its designee may not consider a request for a first-level appeal submitted by a provider under (a) - (g) of this section after the date that the appeal must be submitted.(j) Except under (g) and (h) of this section, a provider that is not satisfied with the first-level appeal decision may file a second-level appeal under 7 AAC 105.280.(k) The provisions of this section do not apply to recoupment actions resulting from audits conducted under 7 AAC 160.100 - 7 AAC 160.130.(l) A provider may not request a first-level appeal of disenrollment under 7 AAC 105.210(d), but may apply for a new enrollment under 7 AAC 105.210.Eff. 2/1/2010, Register 193; am 10/1/2011, Register 199; am 3/19/2014, Register 209, April 2014Authority:AS 47.05.010
AS 47.07.040
AS 47.07.074