Document Citation: 7 Alaska Admin. Code 105.280

Header:

ALASKA ADMINISTRATIVE CODE
TITLE 7. HEALTH AND SOCIAL SERVICES
PART 8. MEDICAID COVERAGE AND PAYMENT
CHAPTER 105. MEDICAID PROVIDER AND RECIPIENT PARTICIPATION
ARTICLE 2. PROVIDER ENROLLMENT, RIGHTS, AND RESPONSIBILITIES

Date:
08/31/2009

Document:

7 AAC 105.280. Second-level provider appeal

(a) A provider may appeal a first-level appeal decision under 7 AAC 105.270(a) -- (f) if the provider submits a written request to the department no later than 60 days after the date of the first-level appeal decision.

(b) A provider that appeals a first-level appeal decision under this section shall

(1) include a description of the issue or decision being appealed;

(2) specify the basis upon which the decision is challenged;

(3) submit all information and materials that the provider requests the department to consider in resolving the appeal, including a copy of the first-level appeal decision; and

(4) submit the appeal 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.

(c) The department will not consider an appeal under this section that is submitted after the date that the appeal must be submitted.

(d) In an appeal by a provider under this subsection of a decision that was denied because the provider failed to timely file a claim, the department will

(1) approve the appeal and pay the maximum amount allowed under 7 AAC 43 and 7 AAC 105 -- 7 AAC 160 if the department 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 (h) of this section 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 determines that the claim was not timely filed.

(e) Except as provided in (g) of this section, a decision by the department under 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.

(f) The provisions of this section do not apply to recoupment actions resulting from audits conducted under 7 AAC 160.100 -- 7 AAC 160.130.

(g) The commissioner may review an appeal of a second-level appeal decision for an untimely filed claim from a provider made under (d) of this section for good cause shown. The provider must submit a written request to the commissioner no later than 60 days after the date of the department's decision made under (d) of this section. A provider shall submit an appeal under this subsection to the Commissioner's Office, Department of Health and Social Services, PO Box 110601, Juneau, Alaska 99811-0601. A decision by the commissioner under this subsection 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.

(h) The department will find good cause for a provider's failure to submit a claim before the billing deadline under 7 AAC 145.005(c) if the failure to submit the claim resulted from a condition that was beyond the provider's control or was caused by a condition that the provider could not reasonably be expected to prevent. In this subsection, a condition beyond the provider's control or a condition that the provider could not reasonably be expected to prevent

(1) includes

(A) a weather condition that causes a mail or travel delay; and

(B) a disaster such as a fire, flood, or earthquake; and

(2) does not include

(A) provider staffing deficiencies; or

(B) the recipient's failure to notify the provider of a court, hearing authority, or department decision described in 7 AAC 145.005(c).