CurrentAlaska MedicaidPolicy N/A

Provider Appeal Procedures — First- and Second-Level Appeals

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This document governs Alaska Medicaid first- and second-level provider appeal processes, deadlines, reasons eligible for appeal, required documentation, and where to send appeals for different service types and departments.

Policy Summary

PayerAlaska Medicaid

PolicyProvider Appeal Procedures — First- and Second-Level Appeals

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit each individual claim appeal separately and send first-level appeals for recoupment within 60 days to First‑Level Appeals, P.O. Box 240808, Anchorage, AK 99524-0808.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daysfirst-level recoupment deadline

180 daysfirst-level certain authorizations

60 dayssecond-level appeal deadline

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CurrentAlaska MedicaidPolicy N/A

Provider Appeal Procedures — First- and Second-Level Appeals

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Policy Summary

PayerAlaska Medicaid

PolicyProvider Appeal Procedures — First- and Second-Level Appeals

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit each individual claim appeal separately and send first-level appeals for recoupment within 60 days to First‑Level Appeals, P.O. Box 240808, Anchorage, AK 99524-0808.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daysfirst-level recoupment deadline

180 daysfirst-level certain authorizations

60 dayssecond-level appeal deadline

Appeal Eligibility and Criteria

Appeal eligibility and procedural criteria

Appeals are accepted for the adverse determinations listed by service type and must meet the submission deadlines and routing requirements shown below.

Appealable items include recoupment of overpayment; denied or reduced claims; and denied or reduced service authorization requests for listed services.

First-level appeals

Each individual claim must be appealed separately for recoupment of overpayment.
First-level appeals for claim recoupment must be submitted within 60 days of the adverse determination.
First-level appeals for denied or reduced service authorization requests for specified services (e.g., durable medical equipment; prosthetics/orthotics; selected drugs; non-emergent transportation and accommodation; selected professional services; services in excess of limits; respiratory therapy; home health; private duty nursing; hospice; CAMA outpatient radiation and chemotherapy; certain maternal/newborn admissions) must be submitted within 180 days of the adverse determination.
Where to send first-level appeals: First-Level Appeals, P.O. Box 240808, Anchorage, AK 99524-0808, except where a different first-level routing is specified for certain service types (see routing nodes).

First-level routing by service type

Non-certification of selected inpatient/outpatient procedures and diagnoses (regardless of length of stay), non-certification of an inpatient stay that exceeded three (3) days, all outpatient MRI/MRA/PET/SPECT, and certain maternal/newborn admissions: send first-level appeals to Comagine Health, Attn: Care Management Dept/Appeal Review, P.O. Box 33400, Seattle, WA 98133-0400 (Phone/Fax provided).
Residential and psychiatric treatment admissions and continued stay reviews (psychiatric admissions and continued stays; Residential Psychiatric Treatment Center admissions and continued stays): send first-level appeals to Comagine Health, P.O. Box 243609, Anchorage, AK 99524-3609 (Fax provided).
Senior and Disabilities Services first-level appeals (administrative wait/swing bed stays, all LTC facility admissions and continued stays, Home and Community-Based Waiver services): send to Department of Health, Division of Senior and Disabilities Services, Attn: Appeal Section, 1835 Bragraw Street Ste 350, Anchorage, AK 99508.
Provider enrollment first-level appeals: send to the second-level appeals address listed for the provider's service type.

Second-level appeals

Second-level appeals must be submitted within 60 days of the first-level appeal determination.
Second-level appeals for most medical and ancillary service categories (e.g., ambulatory surgical services; dental; DME; imaging; hospital services; therapy services; pharmacy; physician/APRN/PA services; home health; hospice; transportation & accommodation; and others) are sent to: Department of Health, Division of Health Care Services, Attn: Appeal Section, 4601 Business Park Boulevard, Bld. K, Anchorage, AK 99503-7167.
Second-level appeals for behavioral health categories (autism services; behavioral rehabilitation; community behavioral health; inpatient psychiatric and residential psychiatric facility services; licensed behavioral health providers; substance use disorder services): send to Department of Health, Division of Behavioral Health, Attn: Appeals Section, 3601 C St Ste.878, Anchorage, AK 99503.
Second-level appeals for Senior and Disabilities Services categories (Community First Choice; Home and Community-Based Waiver; intermediate care facility; personal care assistant; skilled nursing facility; targeted case management): send to Department of Health, Division of Senior and Disabilities Services, Attn: Appeal Section, 1835 Bragaw Ste. 350, Anchorage, AK 99508.

Appeals submitted after the required submission deadline will not be considered and are not eligible for a second-level appeal.

Service Categories and Filing Limits

Service categories eligible for second-level appealsmixed

Ambulatory Surgical Services	Ambulatory Surgical Services
Audiology Services	Audiology Services
Behavioral Health Aide / Community Health Aide / Dental Health Aide Services	Behavioral Health Aide / Community Health Aide / Dental Health Aide Services
Chiropractic Services	Chiropractic Services
Dental Services	Dental Services
Direct-Entry Midwife Services	Direct-Entry Midwife Services
Durable Medical Equipment and Supplies Services	Durable Medical Equipment and Supplies Services
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services	Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services
End-Stage Renal Disease Services	End-Stage Renal Disease Services
Family Planning Services	Family Planning Services

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Timely filing of claims — 12 months from date of service

Timely filing periodClaims must be submitted no later than 12 months from the date services were rendered to the recipient.

ScopeApplies to all claims, including those first filed with a third-party carrier.

Start dateCounting begins from the date services were rendered to the recipient.

How to Submit Appeals and Routing Instructions

Note

First-level appeal submission instructions and timelines — submit each claim separately; deadlines (60/180 days) and other routing rules

Regulation 7 AAC 105.270 requires providers to submit a separate first‑level appeal for each individual claim or determination. Appeals submitted after the required submission deadline will not be considered and are not eligible for second‑level appeal. For recoupment/overpayment requests, submit each claim separately. First‑level appeal submission deadlines: 60 days from the adverse determination for most claims; 180 days for certain authorizations and claims submitted to the fiscal agent as noted below.

Submit each claim or determination as a separate first‑level appeal.
Late appeals will not be considered and are ineligible for second‑level appeal.

Note

First-level appeal routing by service type — where to send appeals for non-certifications, imaging, inpatient/outpatient, etc.

Send first‑level appeals to the address for the service type listed below. Where a specific service group is listed, use the named recipient/agency and address. Key routing rules: Appeals for authorizations and claims submitted to the fiscal agent (denied/reduced claims; denied/reduced service authorization requests for DME, prosthetics/orthotics, selected drugs, non‑emergent transportation/accommodation, selected professional services, services exceeding annual/periodic limits, respiratory therapy, home health, private duty nursing, hospice, CAMA outpatient radiation/chemotherapy, certain maternal/newborn admissions) must be submitted within 180 days of the adverse determination to: First‑Level Appeals, P.O. Box 240808, Anchorage, AK 99524‑0808.

Key Definitions

Claim — definition variants

Definition (variant 1)A bill for services.

Definition (variant 2)A line item of service.

Definition (variant 3)All services for one recipient within a bill.

Clean Claim — can be processed without additional information

DefinitionOne that can be processed without obtaining additional information from the provider of the service or from a third party.

ImplicationNo additional documentation or follow-up is required to adjudicate the claim.

Processing impactClassified as ready for payment determination upon receipt.

Note

Second-level appeal submission and routing — 60-day deadline from first-level determination and routing to Department of Health division

If your first‑level appeal is denied, second‑level appeals must be submitted within 60 days of the first‑level appeal determination. Route second‑level appeals to the Department of Health division responsible for the service area listed below.

For Ambulatory Surgical Services; Audiology; Behavioral Health Aide/Community Health Aide/Dental Health Aide; Chiropractic; Dental; Direct‑Entry Midwife; DME and supplies; EPSDT; ESRD; Family Planning; FQHC & RHC; Home Health; Home Infusion; Hospice; Hospital; Imaging; Independent Lab; Indian Health Services clinic & hospital; Nutrition; Pharmacy; Physician/APRN/PA; Podiatry; Private Duty Nursing; Prosthetic & Orthotic; School‑Based; Therapy (OT/PT/SLP); Transportation & Accommodation — Second‑Level Appeal to be submitted within 60 days to: Department of Health, Division of Health Care Services, Attn: Appeal Section, 4601 Business Park Boulevard, Bld. K, Anchorage, AK 99503‑7167.
For Autism; Behavioral Rehabilitation; Community Behavioral Health; Inpatient Psychiatric and Residential Psychiatric Facility Services; Licensed clinical social worker/marital & family therapist/professional counselor services; Mental Health Physician Clinic; Psychologist; Substance Use Disorder Services — Second‑Level Appeal to be submitted within 60 days to: Department of Health, Division of Behavioral Health, Attn: Appeals Section, 3601 C St Ste. 878, Anchorage, AK 99503.
For Community First Choice; Home and Community‑Based Waiver; Intermediate Care Facility; Personal Care Assistant; Skilled Nursing Facility; Targeted Case Management — Second‑Level Appeal to be submitted within 60 days to: Department of Health, Division of Senior and Disabilities Services, Attn: Appeal Section, 1835 Bragaw St Ste. 350, Anchorage, AK 99508.