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Request for New Consideration of Medical and Dental Services Coverage
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Instructions and required materials for providers/vendors to request that Alaska Medicaid consider coverage of a new or expanded medical or dental service, technology, device, or benefit; applies to providers submitting statewide requests to Alaska Medicaid.
No material clinical or coverage changes in this revision.
Coverage Review Requirements
Do not use this form to request coverage of a non-covered service for an individual patient. This request form is intended for providers and vendors who seek Alaska Medicaid consideration of a new or expanded medical, dental, or device benefit at the program level, not for single-patient exceptions.
Information requirements for coverage review
Coverage consideration will be based on the information the requester supplies addressing the following domains.
Missing information or failure to disclose safety concerns may result in rejection
Evidence should be free of industry bias
Failure to disclose safety concerns may result in rejection of request
Include provider types and settings where alternatives are used
Requested Procedure and Billing Codes
| No codes listed |
How to Submit and Documentation Requirements
Ineligible service types
Request for New Consideration of Medical and Dental Services Coverage: Providers and vendors may request that Alaska Medicaid consider coverage of a new service, technology, or other benefit. Services that are experimental, non‑FDA approved, investigational, or cosmetic will not be considered for coverage. A service may be deemed medically necessary and still not be covered under Alaska Medicaid. The Medicaid Director, in consultation with the Medicaid Medical Director, may approve services at their discretion on a case‑by‑case basis. Do not use this form to request coverage of a non‑covered service for an individual patient.
Required submission documents
Required submission documents: Submit a completed Request for New Consideration of Medical and Dental Services Coverage form, the completed and signed Alaska Medicaid Clinical Coverage Review Request Disclosure form, and relevant research studies and evidence‑based clinical practice guidelines with a complete list of references. Relevant research studies should be free of industry bias and non‑industry supported.
How to submit
How to submit a request: Request an upload link to the Alaska Large File Transfer system by emailing medicaidclinicalreview@alaska.gov with the subject line "New Clinical Request — Documentation Link Needed". Do not attach your submission to that email; instead wait for the upload link. A response will be sent within two business days. Use the upload link you receive to submit all required information.
- Email: medicaidclinicalreview@alaska.gov
- Subject: New Clinical Request — Documentation Link Needed
- Expect response within two business days
Alternatives and item details
Alternatives documentation: As part of your submission include a brief description of current alternative treatments, procedures, medications, or devices (include billing codes if known) and indicate whether the request is for a new benefit or an expansion of an existing benefit. Provide population, expected outcomes, settings of use, provider types, FDA approval status, and whether the item is experimental/investigational/cosmetic.
- Include billing codes when known
- Specify patient population(s) and desired outcomes
- Indicate FDA approval status and whether experimental/investigational/cosmetic
Key Definitions
Background and Scope
This document is an administrative submission form. It requests information from the requester to support Alaska Medicaid’s coverage consideration, including evidence on clinical effectiveness, safety, cost, and existing coverage by other payers or CMS (NCD/LCD) when available. It does not provide clinical guidance; instead, the form collects the data and rationale that Alaska Medicaid staff and medical leadership will use to evaluate whether a service or benefit should be added or expanded under the program.
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