CurrentAlaska MedicaidPolicy N/A

Single Case / Letter of Agreement Request process

Governance of requests for negotiated payment agreements for unique or specialized services not available in Alaska Medicaid; applies to providers and entities seeking single-case payment arrangements and to referring providers assisting with documentation.

Policy Summary

PayerAlaska Medicaid

PolicySingle Case / Letter of Agreement Request process

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the Single Case/Letter of Agreement Request form with required documentation to medicaidclinicalreview@alaska.gov and complete the Case Management Referral before submission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1required primary submission email address

2 business daysallowance for confirmation of receipt

Requiredmember, provider, and request details fields

Checklistrequired supporting documentation list

Submission Requirements for Single Case / Letter of Agreement

Policy Summary

PayerAlaska Medicaid

PolicySingle Case / Letter of Agreement Request process

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the Single Case/Letter of Agreement Request form with required documentation to medicaidclinicalreview@alaska.gov and complete the Case Management Referral before submission.

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

Provide a completed Single Case/Letter of Agreement Request form (checked on form).
Provide relevant medical records to support the request (examples: assessment and plan, lab results, clinical trial information).
Provide an itemized summary of expected costs, including procedure/revenue codes if applicable.
Explain the reason the single case/letter of agreement is requested, including services provided, why current reimbursement methodology is insufficient, alternate treatments/options pursued, and any additional supporting information (use the Explanation of the Request field or attach a separate document if more space is needed).
Include any additional information to support the request.
If applicable
- If the member is entering a long-term care facility, include LTC PASRR Form and LTC Authorization Form.

Operational note: Relevant medical records may be submitted as separate documents along with the request form.

Diagnosis and Procedure Coding; Documentation Checklist

Diagnosis codingICD-10

ICD-10

ICD-10 diagnosis code and description required

Procedure/revenue codesmixed

Procedure/Revenue codes

Itemized summary of expected costs should include procedure/revenue codes if applicable

Documentation completeness — required checklist items

Completed request formCompleted Single Case/Letter of Agreement Request form is required

Relevant medical recordsAssessment and plan, lab results, clinical trial information or other records supporting the request

Itemized cost summaryItemized summary of expected costs including Procedure/Revenue codes (if applicable)

LTC forms (if applicable)For members entering a long-term care facility: LTC PASRR Form and LTC Authorization Form

Any additional informationAny other supporting information to justify the request

How to Submit and What to Include

Prior Authorization

Submission and routing

Submit the completed Single Case/Letter of Agreement Request form and all required documentation to medicaidclinicalreview@alaska.gov; enter 'New Single Case/Letter of Agreement Request' in the subject line. Complete and fax the Case Management Referral form prior to submission. Requests submitted by referring providers will be returned; allow up to two business days for confirmation of receipt and submit email requests encrypted.

Complete Case Management Referral and fax per form instructions before emailing the request
Use subject line: 'New Single Case/Letter of Agreement Request' to ensure correct routing
Email must be encrypted; expect confirmation within two business days
Requests from referring providers will be returned

Documentation Required

Request content requirements

Include requested start and end dates, specify the type of request (Air Ambulance, Inpatient/Outpatient Services, Gene Therapy Treatment, Medication, or Other), and provide location, travel assistance needs, requested rate/payment methodology, and the approximate Alaska Medicaid reimbursement amount.

Requested Start Date and Requested End Date
Type of Request (select applicable option or describe if Other)
Location of Services (city and state)
Indicate if travel assistance will be requested
Requested rate or payment methodology and approximate Alaska Medicaid reimbursement

Documentation Required

Supporting documentation checklist

Provide relevant medical records, an itemized summary of expected costs including procedure/revenue codes (if applicable), and any additional supporting information; if the member is entering long-term care, include the LTC PASRR Form and LTC Authorization Form.

Relevant medical records (assessment and plan, lab results, clinical trial information as applicable)
Itemized summary of expected costs with Procedure/Revenue codes when applicable
Any additional information to support the request
For members entering long-term care: LTC PASRR Form and LTC Authorization Form

Key Terms

Single Case / Letter of Agreement — definition

DefinitionA negotiated payment agreement for unique expertise or specialized services not available in Alaska.

Who completes itThe entity providing the service(s) under the single case or letter of agreement must complete and submit the form with assistance from the referring provider.

Requests from referring providersRequests submitted by referring providers will be returned.

Form presentationTypewritten forms are highly encouraged to reduce review time and improve accuracy.

Case Management Referral — definition

DefinitionA referral form that must be completed and faxed prior to submitting a Single Case/Letter of Agreement Request.

Submission stepComplete the Case Management Referral form and submit it to the fax number on that form before sending the full request.

Routing consequenceThe Case Management Referral must be completed prior to submission to ensure correct processing of the request.