CurrentAlaska MedicaidPolicy N/A

Home Health Service Authorization (SA) Request form

Governance and instructions for submitting, updating, and completing the Alaska Medicaid Home Health Service Authorization request form; applies to providers requesting home health service authorizations for Alaska Medicaid members.

Policy Summary

PayerAlaska Medicaid

PolicyHome Health Service Authorization (SA) Request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and sign the Home Health SA Request form and fax to Alaska Medicaid Fiscal Agent at 888-772-3632.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

fax: 888-772-3632submission channel

one form per SAform rule

signature requiredattestation requirement

include SA numberupdate requirement

Authorization Submission Criteria

Authorization submission criteria

Policy Summary

PayerAlaska Medicaid

PolicyHome Health Service Authorization (SA) Request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and sign the Home Health SA Request form and fax to Alaska Medicaid Fiscal Agent at 888-772-3632.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ALL of the following

Complete the Home Health SA Request form to request initial services or to request a change/update to a previously approved SA (one form per SA).
The completed form must bear the signature of the professional submitting the request; signature attests the form is accurate and meets Alaska Medicaid program requirements.
Submit all Home Health SA requests directly to the Alaska Medicaid Fiscal Agent by fax to 888-772-3632.
Enter the date(s) of service being requested; dates requested should match the dates on the plan of care.
Provide diagnosis and medical justification for the services requested; attach additional documentation as needed.
List specific service lines including revenue code, procedure code, unit/quantity, charges, and dates of service for each requested service line for fiscal agent review and authorization.
Include the approved SA number on the form when submitting an update to an existing/previously approved SA.
Note: Authorization does not guarantee payment; payment is subject to member eligibility and current ID card status.

ref": "b0_0

title": "Authorization submission criteria

What Providers Must Do

Prior Authorization

Submission and update instructions

Complete and sign the Home Health SA Request form and fax to Alaska Medicaid Fiscal Agent at 888-772-3632. To request an update or change to an approved Home Health Service Authorization (SA), include the approved SA number on the form. Complete one form per SA. For further updates, submit a new form.

One form per SA — include the approved SA number when updating an existing authorization.
Fax completed, signed form to Alaska Medicaid Fiscal Agent: 888-772-3632.

Billing Rule

Service detail requirements

Provide complete service detail for each requested service. Ensure dates requested match the plan of care and include medical justification and diagnosis; attach supporting documentation as needed.

Revenue Code: enter the revenue code for the specific type of home health service requested.
Procedure Code: enter the corresponding procedure code (refer to home health billing guidance for acceptable codes).
Unit/Qty: enter the unit(s)/quantity for each requested service.
Charges: enter the total charges for each requested service.
Dates of Service: enter the date(s) of service requested (must match plan of care).
Diagnosis and Medical Justification: include diagnosis and justification; attach additional documentation as needed.

Denial Risk

Payment disclaimer

Authorization does not guarantee payment. Payment is subject to the member's eligibility. Verify the member's current identification card before rendering services. If you received this in error, mail to Alaska Medicaid Fiscal Agent, PO Box 240808, Anchorage, AK 99524-0808.

Key Terms

inv-06: SA (Service Authorization)

DefinitionService Authorization (SA): An approval record for requested home health services; updates to an existing SA require inclusion of the approved SA number on the submitted form.

Update requirementTo request an update or change to an approved Home Health SA, include the approved SA number on the form and submit a completed form for each SA.

Form ruleComplete one form per SA; for further updates complete a new form.

Submission channelFax completed and signed Home Health SA Request form to Alaska Medicaid Fiscal Agent at 888-772-3632.

AttestationThe completed form must bear the signature of the responsible professional attesting that the form content is accurate and meets Alaska Medicaid requirements.

inv-07: Requested services

Required line-item detailEach requested service line must include revenue code, procedure code, unit(s)/quantity, charges, and dates of service.

Revenue code guidanceEnter the revenue code for the specific type of home health services being requested.

Procedure code guidanceEnter the corresponding procedure code for the home health services; refer to home health billing guidance for acceptable procedure codes.

Units and chargesProvide the unit(s)/quantity and the total charges for each requested service line for fiscal agent review and authorization.

Dates must match plan of careEnter the date(s) of service that the services are being requested for; dates requested should match the member's plan of care.

OpenPayer

Home Health Service Authorization (SA) Request form

Authorization Submission Criteria

Home Health Service Codes

What Providers Must Do

Key Terms

Revenue Code	Enter the revenue code for the specific type of home health services being requested.
Procedure Code	Enter the corresponding procedure code for the home health services being requested. Note: Refer to home health billing guidance for acceptable procedure codes.