CurrentAlaska MedicaidPolicy N/A
Pharmacy Claims Management and Prior Authorization
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Governs Alaska Medicaid pharmacy claims processing, prior authorization (PA), step therapy, coordination of benefits/third-party liability, POS claim submissions, and override procedures affecting pharmacies and prescribing providers billing Alaska Medical Assistance.
Policy Summary
PayerAlaska Medicaid
PolicyPharmacy Claims Management and Prior Authorization
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateAug 14, 2019
Last ReviewJun 23, 2014
Next Review DateN/A
Key ActionPrescribers must request prior authorization via Prime Therapeutics at 800-884-3238 or obtain an emergency override (up to a 5-day supply) and then secure full PA.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
up to 5 daysemergency override supply authorized
800-884-3238PA phone (Prime Therapeutics)
366 daystimely filing hard limit
12 monthsstandard timely filing
800-331-4475Clinical Call Center
009661required payer BIN
Coverage, Claims and Payment Rules
Coverage criteria and coordination rules
Covered when ALL of the following apply:
Medications listed on the Prior Authorized Drug List require prior authorization (PA) before Alaska Medical Assistance will cover them; prescribers must request PA via Prime Therapeutics (phone 800-884-3238) or by fax using the PA form.
Emergency dispensing: pharmacies may request an emergency override by contacting Prime Therapeutics; Alaska Medical Assistance may authorize up to a five-day supply but the prescriber must subsequently obtain PA; if PA is denied, the pharmacy will not be reimbursed for the emergency supply.
Step therapy/step-edit: automated step-edit logic may approve certain medications without a separate PA when the recipient's claims/diagnosis history meets criteria; if automated criteria are not met the prescriber must request PA through Prime Therapeutics (800-884-3238).
Coordination of benefits/TPL: Alaska Medicaid is payer of last resort — providers must bill all third-party resources before submitting a claim to Alaska Medical Assistance; after third-party payments are exhausted Alaska will pay the lesser of (Alaska allowed minus other payer payments) or the remaining patient liability less cost-sharing.
Dual eligibles/Medicare coordination: for drugs covered by Medicare Part B pharmacies must bill Medicare Part B first; pharmacies may submit claims for excluded medications to Alaska Medicaid after attempting to bill Medicare Part D, but may not bill Alaska Medicaid for Medicare Part D copays or coinsurance amounts.
Override consideration: claims denied for cost-ceiling or timely filing beyond specified limits (e.g., timely filing >366 days) may be eligible for pharmacy-level override consideration via Prime Therapeutics Clinical/Technical Call Centers; providers should validate submission details before requesting overrides.
Claims handling, filing limits, and submission requirements
Claims adjudication outcomes, denial reasons, and filing/adjustment rules.
Adjudication outcome: if a POS transaction validates claim information and passes edits/audits the claim will pay and appear on the provider's remittance advice; if an edit fails the claim will deny with POS exception codes.
Denied claims: denials occur when information cannot be validated, the billed service is not a program benefit, or a line fails edits/audit; denied lines may be reconsidered if corrected and resubmitted within timely filing limits.
Duplicate billing: duplicate claims are multiple submissions with overlapping identifying data (date of service, charges, recipient ID, provider ID, procedure codes); to avoid duplicates reverse the prior claim and re-bill.
Timely filing: all claims must be filed within 12 months of the date of service; timely filing may be extended for court/administrative orders or for good cause with supporting documentation; claims received after the period must include proof of timely filing (e.g., RA page showing denial, transmission report, correspondence).
Adjustment windows: adjustment requests must be submitted within 60 days from the date of payment or within 12 months of the date of service when additional money is owed to the provider; positive adjustments that owe payment must be completed within 12 months of service.
Paper claims: pharmacies submitting paper claims must use the Universal Claim Form (UCF) and follow UCF completion instructions and required NCPDP D.0 field mappings as specified by the payer.
Overrides and submission requirements
Billing override and required submission elements when dispensing beyond preset limits.
To bill greater than the maximum dispensing limit, the pharmacy must submit Submission Clarification Code field 420-DK with value 02 (Other Override).
Include required UCF/NCPDP fields per payer specifications (e.g., NDC, days supply, quantity dispensed, gross/net amounts) when submitting override claims.
Compound-specific rules: compound claims must include designated NCPDP fields and per-ingredient NDCs as required; compound ingredient component count (447-EC) must reflect number of ingredients and is limited per compound rules.
Provider identifiers: ensure correct program BIN and processor fields (e.g., BIN 009661) and other required payer identifiers are submitted to avoid processing errors.
Special coverage criteria
Special-case coverage and override criteria for specific recipient settings and services.
Long-term care and hospice rules
- LTC claims: submit Patient Residence Code (NCPDP 384-4X) = 4 (Assisted Living) to identify LTC recipients; early refill tolerances do not apply to LTC; OTC meds are not covered except insulin; entering the patient residence code may enable overrides of opioid quantity limits.
- Hospice claims: submit Patient Residence Code (384-4X) = 11 (Hospice) to bypass some opioid maximum daily quantity limits and certain PA requirements.
340B billing: covered entities must submit Submission Clarification Code 20 for 340B claims; bill only the 340B acquisition cost plus dispensing fee; contract pharmacies must carve out Alaska Medicaid reporting accordingly.
Compounded medications: compounds are covered when commercially available products cannot meet therapy needs, must contain at least one covered outpatient drug, and pharmacies must submit NDC and quantity for each covered ingredient; Medicaid will not reimburse more than 25 covered outpatient drugs in any compound.
Postage/freight: reasonable postage/freight is reimbursable when shipping is necessary; one postage fee per claim up to $16, prorated across multiple mailed prescriptions.
Vaccine administration: pharmacists may bill an administration fee using the designated NCPDP fields (e.g., 480-H9 with appropriate qualifier) and submit appropriate dispensing fee handling (dispensing fee may be $0.00 where specified).
Tobacco cessation counseling incentive: pharmacies may bill the incentive once monthly using the designated field (438-E3) up to $16.00.
Home infusion therapy: submit home infusion claims as multi-ingredient/compound claims per NCPDP guidance; for non-LTC recipients do not bill a dispensing fee (submit 412-DC as $0.00) because preparation/delivery are reimbursed via per diem; LTC home infusion may be eligible for a dispensing fee per compounded medications guidance.
Cost Sharing and Exemptions
Cost-sharing amounts and populations exempt from copayments.
Pharmacy copay amounts: collect $0.50 per prescription for payments of $50 or less, and $3.50 per prescription for payments greater than $50.
Exemptions from cost sharing: no copay for recipients under 18, long-term care residents, pregnant women (eligibility code 11), family planning services, hospice services, services provided by tribal health programs to American Indians/Alaska Natives, Medicare-primary services, emergency services, and specified blindness/disability exam services (eligibility codes 15 and 25).
CAMA recipients: eligible CAMA recipients have no copayment for covered pharmacy claims.
Overpayment Recovery
Conditions under which Alaska Medical Assistance will recover overpayments and recognized exceptions.
Overpayment recovery: Alaska Medical Assistance will recover overpayments for reasons including services billed without required service authorization, payments exceeding maximum allowable, non-covered services, services not rendered, services paid by third-party resources, duplicate billing, ineligible recipients, and MMIS errors.
Recoupment process: repayment may be accomplished by refund check with an AK-05 form or by recoupment (reducing future payments); providers will be notified on the remittance advice when recoupment occurs within 120 days, or provided at least 60 days' written notice if recoupment begins after 120 days.
Exceptions: recovery does not apply to probate collections or providers who are bankrupt, out-of-business, or under sanction actions.
Adjustments and Voids
Rules and timeframes for adjusting or voiding paid claims.
Adjustments (general): providers must submit adjustments to correct paid claims (procedure code, charges, days, third-party payments, SA updates) and may submit electronically as an 837 claim replacement or on AK-05 for paper requests.
Adjustment timing: positive adjustments (resulting in additional payment to the provider) must be completed within 12 months of the date of service or within 60 days of payment; if additional money is owed to Alaska Medical Assistance the 60-day limitation does not apply.
Third-party adjustments: when third-party payments change, submit an adjustment with the attached EOB; failure to attach the EOB may result in recoupment of prior payments rather than a partial adjustment.
Voids: providers may request voids only for paid claims using AK-05 or electronic 837 replacement; voids are granted with no time limit and will refund the full payment and remove the paid claim from history (records retained).
Denied Claims
Actions to resolve denied claim lines and special-case guidance.
Denial resolution: when a claim line is denied, submit a new corrected claim referencing the EOB code guidance; resubmit corrected information within timely filing limits for reconsideration.
Third-party liability denials: bill third-party resources first and rebill Alaska Medicaid with EOB or proof of non-coverage within the 12-month timely filing period.
Eligibility denials: verify recipient eligibility and seek retroactive eligibility if applicable, then re-bill after eligibility is updated.
Missing service authorization: verify the submitted SA number; if SA was not obtained, contact the authorizing agency for instructions and resubmit as directed.
Timely filing denials: if denied for exceeding timely filing limits, file an appeal within 180 days and include proof/documentation as required to support timely filing exceptions.
Payment & Remittance Delivery
Methods of payment and electronic remittance delivery requirements.
Payment methods: Alaska Medical Assistance pays providers via EFT or state treasury warrant; to receive EFT providers must submit an Update EFT form; state warrants should be redeemed within 120 days.
Endorsement certification: endorsing a check certifies the claim is true and accurate unless the provider notifies Alaska Medical Assistance of an error within 30 days of negotiation.
Electronic Remittance Advice (RA): providers may request electronic RA (835) by completing an Electronic Remittance Authorization Form; providers must submit HIPAA-compliant 837 transactions to receive 835 responses and only one entity may receive the electronic RA for a provider.
Claims handling and appeals criteria
Criteria and timeframes for reconsideration, adjustments, voids, appeals, and price reviews.
Denial resolution pathways
- Denied for third-party liability: bill third parties first and rebill Medicaid with EOB or proof of non-coverage within 12 months.
- Denied for recipient eligibility: verify eligibility, seek retroactive coverage, then rebill.
- Denied for non-coverage or coding issues: verify appropriate/current procedure codes for date/provider/recipient and resubmit corrected claim.
- Denied for missing service authorization: verify SA number submitted or contact the authorizing agency for instructions.
- Denied for exceeding timely filing: file an appeal within 180 days of the RA decision.
Adjustments: submit AK-05 or 837 replacement to adjust paid claim elements (procedure, charges, days, third-party payments, SA updates); positive adjustments must be within 12 months of date of service when payment is owed; attach EOBs for third-party adjustments to avoid full recoupment.
Voids: request voids for paid claims with wrong recipient/contract ID, services not rendered, or when paid by Medicare after Medicaid payment; voids have no time limit and will refund Alaska Medical Assistance the full payment.
Appeals: first-level appeals must be written and received within 180 days of the RA (include RA, original claim, supporting documents); second-level appeals must be postmarked within 60 days of first-level decision; final appeals must be postmarked within 60 days of second-level decision and are submitted to the DHSS Commissioner (applicable for timely filing denial appeals).
NADAC/SMAC price review: to request reconsideration of a SMAC price submit the NADAC Request for Medicaid Reimbursement Review form with NDC and invoice of current acquisition cost to Prime Therapeutics; Prime will respond within three days and may adjust SMAC retroactively if warranted.
Coding, Transactions and Claim Fields
Procedure code billing scrutinyCPT
| CPT | Procedure codes subject to Alaska Medical Assistance examination for reimbursement (incidental, mutually exclusive, unbundling, invalid modifier combinations, units expansion, same services billed by multiple providers). |
NCPDP Version D.0 transaction codesmixed
| B1 | Claim Billing — submit original claims. |
| B2 | Claim Reversal — cancel previously processed paid claim (must match key fields: Service Provider ID, Prescription Number, Date of Service, NDC). |
| E1 | Eligibility Verification — used to determine recipient eligibility; rarely used because claim transaction provides eligibility. |
drug and clinical codingNDC | mixed
| NDC | Product/Service ID uses National Drug Code for non-compound claims (NCPDP field 37). |
| DAW codes (0-9) | Dispense As Written codes for substitution and brand/generic handling (NCPDP field 42). |
| ICD-10 | Diagnosis code qualifier 02 = ICD-10 (used when diagnosis affects payment or substitutes for prior authorization). |
Compounded medication claim fieldsNDC
| 406-D6 | Compound code (2 = Compound). |
| 488-RE | Compound product ID qualifier (03 = National Drug Code for each ingredient). |
| 447-EC | Compound ingredient component count (number of ingredients; maximum 25). |
| 409-D9 | Ingredient cost submitted (total ingredient cost for the compound; must equal sum of ingredient drug costs 449-EE). |
| 412-DC | Dispensing fee submitted. |
| 420-DK | Submission clarification code (8 = Process compound for approved ingredients; used for compounds with rebateable and non-rebateable ingredients). |
Vaccine administration claim fieldsmixedCovered
| 480-H9 | Other amount claimed submitted — amount claimed for vaccine administration fee. |
| 478-H8 | Other amount claimed qualifier — 04 = Administrative cost. |
Override for dispensing limitsmixedCovered
| 420-DK | Submission Clarification Code — 02 = Other Override (submit to bill greater than maximum dispensing limit). |
TCN formatmixed
| YYJJJMBBBBDDDDDDT | Transaction Control Number (TCN) format used to track claims (YYJJJ = Julian date, M = media source code, BBBB/DDDDDD = internal Conduent use, T = transaction type). |
Coding edits and appealsmixed
| NCCI edits | Procedure-to-procedure edits, medically unlikely edits, units of service edits — providers must appeal individual claim denials resulting from NCCI edits following the prescribed appeal levels and timelines. |
inv-19: TPL handling thresholds
TPL handling outcomesUses NCPDP D.0 TPL Processing Grid: scenarios (Other Payer Amount Paid > $0.00, = $0.00, payment not collected) determine claim disposition and required NCPDP fields (e.g., 431-DV, 443-E8, 340-7C, 352-NQ)
Required Other Payer fieldsWhen other coverage exists include Other Payer Amount Paid (431-DV), Other Payer Date (443-E8), Other Payer ID (340-7C), and Other Payer Patient Responsibility (352-NQ)
Disposition rulesGrid indicates payer will pay the lowest of (Alaska allowed minus other payer amount) or submitted patient responsibility; certain reject codes (65–70) accepted when other payer not covering
inv-20: Required data elements
Mandatory transaction segmentsHeader, Patient, Insurance, Claim, Prescriber segments are required for B1 (original) transactions per NCPDP D.0; some segments required for B2 reversals
Alaska required identification fieldsANSI BIN (009661), Processor Control # (P013009661), Group (AKMEDICA), Provider ID = NPI, Cardholder ID = Recipient ID, Product Code = NDC (see payer specs)
Processing requirementAlaska Medical Assistance will not process claims without all required data elements; see Alaska Medicaid Payer Specifications for full field mapping
inv-21: Compound ingredient limit
Maximum ingredients per compoundAlaska Medicaid will not reimburse for more than 25 covered outpatient drugs in any compounded medication (Compound ingredient component count — NCPDP 447-EC)
Compound submission fieldsSubmit NDC and quantity for each covered outpatient drug ingredient (Product code/NDC 407-D7, Product ID qualifier 488-RE=03 for NDC)
Separate claim per compoundUse a separate claim form for each compound prescription and list first ingredient on line 1 with remaining ingredients on subsequent lines
inv-22: max_postage_per_claim
Per-claim postage capPostage/freight reimbursable per claim up to $16; when mailing multiple prescriptions prorate total postage across claims
Postage submission fieldsUse Other amount claimed (480-H9), qualifier 479-H8=03 (Postage Cost), and count 478-H7 to submit postage amount
Documentation requirementRetain documentation of postage costs per 7 AAC 105-160; not reimbursable when local pharmacy services are available
inv-23: max_compound_ingredients
Max covered ingredientsMaximum number of covered outpatient drug ingredients reimbursed in a compound = 25 (Compound ingredient component count — NCPDP 447-EC)
NCPDP fields for compoundsRequired compound fields include Compound code (406-D6), Product/Service ID (407-D7), Product ID qualifier (488-RE), Ingredient component count (447-EC), Ingredient drug cost (449-EE)
Formatting and routingUse appropriate route of administration codes (995-E2) and list product name and NDCs on separate lines; separate claim per compound
inv-24: Pharmacy cost-share conditional threshold
Pharmacy cost-share ceiling triggerPatient cost-sharing thresholds reference $50: for payment ≤ $50 collect $0.50; for payments > $50 collect $3.50 per prescription
Cost-share exemptionsExempt from cost sharing: recipients under 18, LTC facility services, pregnant women (eligibility code 11), family planning, hospice, tribal health program recipients, Medicare-primary services, emergency services, blindness/disability exam codes 15 and 25
Inpatient/outpatient thresholdsMedicaid cost sharing also specifies $50/day up to $200 per discharge for inpatient services and 5% of allowable charges for outpatient hospital services
inv-25: Adjustment submission window (positive adjustment)
Positive adjustment windowAll positive adjustments (when additional payment is owed to provider) must be submitted within 12 months of the date of service
Method of submissionAdjustments may be submitted electronically via 837 claim replacement or by AK-05 Adjustment/Void Request Form for paid claims
No-time-limit exceptionsIf no money is owed to Medicaid or the adjustment does not affect payment, there is no time limit for submission
Provider Requirements, Overrides and Submission Guidance
Prior Authorization
Prior Authorization for Prescribed Medications
Certain medications on the Prior Authorized Drug List require prior authorization (PA) before Alaska Medical Assistance will cover them. The prescriber must request PA by calling Prime Therapeutics State Government Solutions at 800-884-3238 or faxing a completed PA form; in emergencies the pharmacy may call 800-884-3238 for an override authorizing up to a five-day supply, but the prescriber must still obtain PA or the pharmacy will not be reimbursed if PA is later denied.
- Request PA via Prime Therapeutics phone 800-884-3238 or fax a completed PA form.
- Emergency override may authorize up to a five-day supply, but subsequent PA must be obtained.
Step Therapy
Step Therapy Authorization
Step therapy (step-edit) may auto-authorize some PA drugs when the recipient's pharmacy and medical claim history or diagnosis supports approval; if automated criteria are not met the prescriber must request PA from Prime Therapeutics at 800-884-3238.
- Automated step-edits evaluate claims/diagnosis history for approval.
- If criteria fail, prescriber must contact Prime Therapeutics (800-884-3238) to request PA.
Prior Authorization
PA Call Centers and Pharmacy-Level Overrides
PA requests, clinical override consideration, and pharmacy-level overrides are handled by Prime Therapeutics Medicaid Administration via the Clinical Call Center (800-331-4475), the Technical Call Center, or direct pharmacy level overrides; providers should contact the appropriate call center for override consideration for dollar limits, timely filing, lock-ins, ProDUR and other specified denial reasons.
- Clinical Call Center phone: 800-331-4475 (fax also provided where applicable).
- Validate submitted claim details (quantity, dates) before requesting overrides for dollar limits, timely filing, or lock-ins.
- Provider-level overrides (e.g., ProDUR, COB) are allowed using the designated override codes when conditions are met.
Billing Rule
Cost Ceiling Overrides
Claims with a dollar amount exceeding the prescription medication cost ceiling will initially deny; the pharmacy must contact Prime Therapeutics at 800-884-3238 to request authorization to override the cost-ceiling edit when the medication is medically necessary.
- Contact Prime Therapeutics State Government Solutions (800-884-3238) to request a cost-ceiling override.
- Claims will initially deny until override is authorized.
Documentation Required
Point-of-Sale submission and exception resolution guidance
Submit claims via the Point-of-Sale (POS) system to receive real-time eligibility, drug coverage, pricing, PA guidance and immediate adjudication; review POS exception (four-digit) codes, correct the underlying issue(s), and resubmit when appropriate.
- POS returns instant adjudication: pay or deny with exception codes.
- An exception is a four-digit code indicating eligibility, coverage, interaction, early refill, etc.; address the first exception and be aware additional exceptions may still apply.
- Correct errors identified by POS and resubmit the claim.
Billing Rule
Prior authorization and overrides (claim field guidance)
Include prior authorization and override indicators on the claim: submit the prior authorization number in NCPDP field 43 (462-EV) and use Submission Clarification Code (420-DK) = 02 (Other Override) to bill greater than the maximum dispensing limit.
- Enter the PA number in Field 43 / 462-EV as provided by Alaska Medical Assistance.
- To bill over maximum dispensing limit, set Submission Clarification Code 420-DK = 02 (Other Override).
Documentation Required
LTC/Hospice residence coding
Enter the Patient Residence Code (NCPDP 384-4X) to identify long-term care or hospice residence so LTC/hospice specific overrides and quantity-limit exceptions will apply.
- Use Patient Residence Code 384-4X (e.g., 4 = Assisted Living) for LTC overrides.
- Hospice residence coding enables bypass of some opioid daily quantity limits for hospice recipients.
Billing Rule
340B billing requirement
For 340B drugs, submit Submission Clarification Code 20 (420-DK) and report the submitted ingredient cost or billed amount as the 340B acquisition cost (340B ceiling price); contract pharmacies must carve out Alaska Medicaid and may not bill for 340B product.
- Set SCC 420-DK = 20 for all 340B claims.
- Submitted ingredient cost must be the lesser of actual acquisition cost or 340B ceiling price; do not bill pre-rebate purchase price.
Documentation Required
ProDUR override coding
When overriding a ProDUR denial, submit the DUR Professional Service (Intervention Code) in NCPDP field 440-E5 and the DUR Result of Service (Outcome Code) in field 441-E6 documenting the intervention and outcome per ProDUR guidance.
- Populate 440-E5 with the appropriate Intervention/Professional Service code.
- Populate 441-E6 with the corresponding Result of Service/Outcome code to adjudicate an overridden ProDUR alert.
Billing Rule
Home infusion dispensing fee
For home infusion therapy provided to recipients not in long-term care, do not bill a dispensing fee; submit Dispensing Fee Submitted (412-DC) as $0.00 and bill the home infusion per diem instead. For home infusion provided in LTC, a dispensing fee may be submitted per compounded medication guidance.
- If patient is not in LTC, set 412-DC = $0.00 (no dispensing fee) and bill per diem.
- If patient is in LTC, follow compounded medication guidance to claim a dispensing fee where allowed.
Billing Rule
Postage/freight claim submission
To claim postage/freight, submit Other Amount Claimed (480-H9) with qualifier 479-H8 = 03 (Postage Cost) and count 478-H7; a single postage amount per claim is allowed up to $16 and postage must be prorated across multiple prescriptions mailed together.
- Use 480-H9 for postage amount, 479-H8 = 03 to indicate postage, and 478-H7 for count.
- Per-claim postage reimbursement must not exceed $16 and must be prorated when shipping multiple prescriptions.
Denial Risk
Service Authorization and Denials
Obtain and include required Service Authorization (SA) numbers when an SA is required; claims billed without the required SA are subject to denial and recovery/recoupment.
- Claims lacking required SA may be recovered as overpayments.
- Verify SA numbers on claims to avoid denials and potential recoupment.
Documentation Required
Service Authorization Issues on Denied Claims
If a claim is denied for missing service authorization information, verify the SA number submitted and, if SA was not obtained, contact the authorizing agency for instructions; follow the authorizing agency's direction before resubmitting.
- Verify accuracy of the SA number submitted on the claim.
- Contact the authorizing agency if SA was not obtained to determine next steps.
Billing Rule
Adjustments and Voids (provider steps)
Submit adjustments to correct paid claims (procedure codes, charges, days, third-party payments, SA updates) using an 837 replacement or AK-05 form; positive adjustments that increase payment must be submitted within 12 months of the date of service (or within 60 days of payment per other filing guidance). To void a paid claim, request a void (AK-05) when recipient/contract IDs are incorrect, services were not rendered, or Medicare subsequently paid—void requests have no time limit.
- Use AK-05 or 837 replacement for adjustments/voids as appropriate.
- Positive adjustments that result in additional payment must be submitted within 12 months of date of service.
- Void requests are granted with no time limit; always void claims paid by Medicare after Medicaid payment.
Definitions and Key Identifiers
inv-40: Payer of last resort
Payer of last resort definitionAlaska Medicaid is the payer of last resort; pharmacies must bill all third-party resources before submitting claims to Alaska Medical Assistance
Payment calculation after TPLAlaska will pay the lesser of (Alaska allowed minus other payer payments) or the remaining patient liability less cost-sharing
Medicare coordinationFor dually eligible recipients, Medicare benefits must be exhausted before billing Alaska Medicaid; Medicare Part D patient liability cannot be billed to Medicaid
inv-41: Point of Sale (POS)
POS capabilitiesPoint-of-Sale (POS) provides real-time eligibility, drug coverage, cost-containment pricing, prior authorization guidelines, and dispensing fees, returning instant adjudication (pay or deny)
Immediate responseAfter POS submission the system returns a message indicating outcome; if all edits pass a 'Paid' message with allowed amount is returned; failing edits return denial messages
Use for exception resolutionProviders should review POS exception codes and correct/resubmit claims as appropriate to resolve denials
inv-42: Exception (POS explanation code)
POS exception code meaningAn exception is a four-digit explanation code returned on a POS transaction indicating outcome and reasons edits failed (eligibility, coverage, interactions, early refill)
Multiple exceptionsMore than one exception may apply; providers may address the first listed exception but subsequent exceptions can still hold up the claim
Corrective actionRead exception descriptions carefully to identify and correct errors before resubmitting claims
inv-43: B1/B2 transactions
Accepted transaction typesAlaska accepts NCPDP Version D.0 Transaction Codes B1 (Claim Billing) for original claims and B2 (Claim Reversal) for reversals; B3 transactions are no longer accepted
Reversal matching fieldsVoids/Reversals must match Service Provider ID, Prescription Number, Date of Service, and NDC to be successful
E1 eligibility useE1 (Eligibility Verification) exists but is rarely used because eligibility is included in claim transactions
inv-44: Key electronic identifiers
Program identifiersANSI BIN = 009661; Processor Control # = P013009661; Group name = AKMEDICAID; Provider and Prescriber ID = NPI; Cardholder ID = Recipient Identification Number
Required software/vendor IDSoftware Vendor/Certification ID assigned when certified with Prime Therapeutics Medicaid Administration; claims will reject if missing or invalid
Date formatDate of Service must be formatted CCYYMMDD
inv-45: Key payer identifiers
Recipient and payer fieldsUse NCPDP Field 302-C2 for Recipient Medicaid ID, Plan name (301-C1) = AKMEDICAID, BIN (101-A1) = 009661, Processor control (104-A4) = P013009661
Product and substitution fieldsProduct/Service ID (407-D7) = NDC for non-compound claims; DAW codes (field 42 / 408-D8) enumerate substitution rules 0–9
Other coverage indicatorUse Other Coverage field (45 / 308-C8) to indicate 0/2/3/4 values per payer rules
inv-46: Product and substitution fields
Product/Service ID ruleField 37 (Product/Service ID / 407-D7) must contain the NDC for non-compound claims; enter '0' for compound claims
DAW (substitution) codesField 42 (DAW / 408-D8) required: 0 = No product selection indicated; 1 = Substitution not allowed by prescriber; up to 9 = plan/patient request rules
Days supply and quantityField 41 (405-D5) = Days supply and Field 40 (442-E7) = Quantity dispensed are required and used in adjudication
inv-47: Diagnosis fields
Diagnosis code qualifierUse Diagnosis Code Qualifier field (field 50) value 02 for ICD-10 when submitting diagnosis codes relevant to payment or to substitute for prior authorization
Compound-related diagnosis fieldsInclude diagnosis and route of administration when necessary for adjudication; route codes required for some compound claims (995-E2)
When to include diagnosisProvide diagnosis when it affects payment or can substitute for prior authorization information
inv-48: 340B actual acquisition cost
340B acquisition cost requirementFor 340B drugs providers must submit ingredient cost equal to the 340B acquisition cost (340B ceiling price); do not bill pre-rebate purchase price
Submission clarification codeSubmit Submission Clarification Code 420-DK = 20 to identify 340B claims; such claims are excluded from Medicaid drug rebate invoicing
Contract pharmacy restrictionContract pharmacies are not allowed to bill Alaska Medicaid for 340B product and must carve out Alaska Medicaid
inv-49: ProDUR
ProDUR purposeProspective Drug Utilization Review (ProDUR) performs detection, evaluation, and counseling pre-dispensing to identify potential drug therapy problems
Override documentationTo override a ProDUR denial submit DUR Professional Service (440-E5) and DUR Result of Service (441-E6) documenting the intervention and outcome
Operational scopeProDUR examines claims across participating pharmacies and is integrated into adjudication to detect interacting or high-risk therapies
inv-50: Pricing Methodology (In-State)
In-state pricing ruleIn-state providers reimbursed at the lesser of: billed charges, provider-type rate, or provider's lowest charge (with specified exclusions)
Exclusions to 'lowest charge' ruleExcludes sliding fee scale policies, certain discounted contracts, employer benefit discounts, and federal/state government contracts (including Medicare)
Provider-type specificityPricing methodology is specific to each provider type; refer to Section I for provider-type rates
inv-51: Remittance Advice (RA)
Remittance Advice (RA) purposeRA is a weekly claim status report listing messages, adjudicated/adjusted/in-process/voided claims, EOBs, and remittance summary for enrolled providers
Use of RAProviders must read and reconcile the RA each week to identify claims requiring action and to stay informed of policy and reimbursement changes
TCN trackingClaims are identified and tracked on the RA by Transaction Control Number (TCN)
inv-52: Recoupment / Overpayment Recovery
Recoupment definition and causesRecoupment is reduction of future payments to offset identified overpayments; causes include missing SA, exceeding maximum allowable, non-covered services, duplicate billing, ineligible recipients, MMIS errors
Provider notification timingProvider notified by remittance advice when recoupment occurs within 120 days; if over 120 days provider receives written notice at least 60 days before recoupment
Repayment methodsRepayment may be by refund check with AK-05 form or by recoupment from future payments; provider may be required to repay balance in writing if they stop billing
inv-53: AK-05 Adjustment/Void Request Form
AK-05 form useAK-05 Adjustment/Void Request Form is used to request adjustment or void of paid claims and may be submitted by mail, fax, or electronically via 837 replacement
AK-05 limitationsAK-05 may be used only for paid claims; voids and adjustments for paid claims must be requested via AK-05 or 837 replacement
Supporting documentationInclude required supporting documentation when requesting adjustments or voids (e.g., EOBs, corrected claim data)
inv-54: NADAC Review Form
NADAC review purposeNADAC Request for Medicaid Reimbursement Review form is used to request reconsideration of a SMAC price; include NDC and current acquisition cost invoice
Response timePrime Therapeutics will investigate and respond within three days and may adjust SMAC retroactively if warranted
Effect of adjustmentIf SMAC is adjusted, Prime will notify the provider to resubmit claims using the adjusted price with retroactive effective date as applicable
Policy Summary
PayerAlaska Medicaid
PolicyPharmacy Claims Management and Prior Authorization
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateAug 14, 2019
Last ReviewJun 23, 2014
Next Review DateN/A
Key ActionPrescribers must request prior authorization via Prime Therapeutics at 800-884-3238 or obtain an emergency override (up to a 5-day supply) and then secure full PA.
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OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.