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Prior Authorization

Alaska Medical Assistance: Alaska Medicaid, Denali KidCare and Chronic & Acute Medical Assistance

Prior Authorization is required and issued for Alaska Medical Assistance recipients by the following authorizing entities based on service category:

Recipients:

Many health care services require prior authorization. It is the responsibility of your medical provider to contact the appropriate agency to authorize these service before providing the service. If you are a recipient and have questions about your coverage call the Recipient Helpline: 1 (800) 780-9972.

Health Care Providers:

Many health care services require authorization prior to services being administered. Four agencies are currently approved to provide "Prior Authorization" for Alaska Medical Assistance recipients. Each agency, listed below, provides prior authorization for specific services. Please view the services under each agency to determine the appropriate agency contact.

Alaska Medical Assistance

Please call Xerox State Healthcare, LLC: (907) 644-6800 or in-state toll-free number: (800) 770-5650.

Provider Inquiry/Provider Services: (907) 644-6800 (option 1) or toll-free: (800) 770-5650 (option 1, 1).

Prior Authorization by Xerox includes the following services:
  • all non-emergent, medically necessary transportation and accommodation services
  • selected professional services (physician, advanced nurse practitioner, medical clinic, dentist, etc) as indicated in billing manuals/fee schedules
  • services in excess of annual or periodic service limitations stipulated in regulations (vision, mental health, substance abuse rehabilitation, etc) as indicated in manuals/fee schedules
  • most Durable Medical Equipment, selected medical supplies, and selected hearing aids as indicated in billing manuals/fee schedules
  • all Respiratory Therapy
  • all Home Health Care Services
  • all private duty nursing
  • all hospice care
  • Chronic & Acute Medical Assistance (CAMA) program recipients requiring outpatient radiation and chemotherapy
  • certain maternal/newborn admissions (see chart below)

    Maternal/Newborn Stay Prior Authorization (PA) Chart

    Mode of Delivery Submit Claims as Payable without PA Administrative PA from Xerox Medical Necessity Review from Qualis
    Vaginal Delivery Total stay from admit to discharge is 2 days or less Delivery/Birth is the day after admission, but discharge is within 2 days of delivery/birth Either delivery/birth is more than one day after admission OR discharge is more than 2 days following date of delivery/birth
    Cesarean Delivery Total stay from admit to discharge is 4 days or less Delivery/Birth is the day after admission, but discharge is within 4 days of delivery/birth Either delivery/birth is more than one day after admission OR discharge is more than 4 days following date of delivery/birth

  • selected pharmaceutical drugs as specified on Drugs Requiring Prior Authorization

Prior Authorization general form 0707

See prior-authorized drugs

Division of Senior and Disabilities Services (DSDS)

Monday - Friday 8:00am - 4:30pm (AK time)
(907) 269-3666 or (800) 478-9996
(907) 269-3688 Facsimile
http://hss.state.ak.us/dsds

The Division of Senior & Disabilities Services provides Prior Authorization for the following services:

  • administrative wait and swing bed stays at acute care facilities and all long term care (LTC) facility admissions and continued stays
  • Home and Community-Based Waiver Services
  • Personal Care Attendant (PCA) services

Qualis Health

Monday - Friday 6:30am - 6:00pm (AK time)
(800) 783-9207
(800) 826-3630 - Facsimile
http://qualishealth.org

Qualis provides Prior Authorization for the following services:

  • selected inpatient and outpatient procedures and diagnoses, regardless of length of stay (see Select Diagnoses and Procedures PRE-CERTIFICATION List)
  • all inpatient hospital continued stays exceeding three (3) days
  • certain maternal/newborn admissions
  • Outpatient Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Positron Emission Tomography (PET), and Single-Photon Emission Computed Tomography (SPECT)

Select Diagnoses and Procedures PRE-CERTIFICATION List

Outpatient Imaging Pre-certification List

Maternal/Newborn Stay Prior Authorization (PA) Chart

Mode of Delivery Submit Claims as Payable without PA Administrative PA from Xerox Medical Necessity Review from Qualis
Vaginal Delivery Total stay from admit to discharge is 2 days or less Delivery/Birth is the day after admission, but discharge is within 2 days of delivery/birth Either delivery/birth is more than one day after admission OR discharge is more than 2 days following date of delivery/birth
Cesarean Delivery Total stay from admit to discharge is 4 days or less Delivery/Birth is the day after admission, but discharge is within 4 days of delivery/birth Either delivery/birth is more than one day after admission OR discharge is more than 4 days following date of delivery/birth

 

Health Care Management (HCM)

Monday - Friday 8:00am - 5:00pm (AK time)
(800) 783-9207
(800) 826-3630 - Facsimile
http://qualishealth.org

Health Care Management provides Prior Authorization for the following services:

  • Psychiatric admissions and continued stays
  • Residential Psychiatric Treatment Center (RPTC) admissions and continued stays