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(16) an administrative-wait or swing-bed stay at a general acute care hospital;

(17) a long-term care facility admission or continued stay;

(18) home and community-based waiver services under 7 AAC 130;

(19) personal care services under 7 AAC 125.010 — 7 AAC 125.199;

(20) behavioral health services identified in 7 AAC 135 as requiring prior authorization;

(21) surgical procedures to alter a recipient’s body to conform to the recipient’s gender identity;

(22) therapy services identified in 7 AAC 115.110, 7 AAC 115.210, 7 AAC 115.310, and 7 AAC 115.410 as requiring prior authorization. (b) Except as provided in 7 AAC 140.320, failure to obtain the required prior authorization may result in nonpayment, regardless of the eligibility of the recipient or the appropriateness of the services. (c) For prior authorization, factors that the department will consider include the service’s medical necessity, clinical effectiveness, cost-effectiveness, and likelihood of adverse effects, as well as service-specific requirements in 7 AAC 105 — 7 AAC 160. The department may place minimum or maximum quantities allowed of a specific service, may require other services before the recipient receives the requested service, or may require prior authorization for other services, as necessary

(1) for the protection of the public health, safety, and welfare;

(2) to prevent waste, fraud, and abuse of the Medicaid program; or

(3) to maintain the financial integrity of the department and the Medicaid program. (d) The department may pay for a service under (a) of this section without prior authorization if prior authorization was not possible before the service was provided or a claim for payment is being processed after the service was provided following determination of a recipient’s retroactive eligibility under 7 AAC 100.072. (Eff. 2/1/2010, Register 193; am 10/1/2011, Register 199; am 3/19/2014, Register 209; am 7/25/2021, Register 239; am 3/3/2023, Register 245; am 2/1/2025, Register 253) Statutory Authority: Authority: AS 47.05.010 AS 47.07.030 AS 47.07.040