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(1) the items meet national quality standards as defined by the National Association for Continence (NAFC);

(2) the items are medically necessary for a medical condition resulting in bladder or bowel incontinence;

(3) the recipient has not responded to, would not benefit from, or has failed bowel or bladder training;

(4) the quantities prescribed do not exceed those established on the Alaska Medicaid DMEPOS Fee Schedule, Tables I-5 through I-9, adopted by reference in 7 AAC 160.900, except that subject to a service authorization required under 7 AAC 120.210, a provider may request and the department may pay for medically necessary incontinence supplies in quantities exceeding those on the Alaska Medicaid DMEPOS Fee Schedule, Tables I-5 through I-9, adopted by reference in 7 AAC 160.900, if a clinical assessment of need and plan attested to by the prescriber is submitted by the servicing provider; and

(5) the items are prescribed on a form that includes the items required by (t) of this section, and documentation of clinical assessment and medical necessity, certified at least annually by a physician, physician assistant, or advanced practice registered nurse who is enrolled under 7 AAC 105.210 and is acting within the scope of that person’s license. (q) In addition to meeting the requirements in 7 AAC 105.230, a recipient’s medical record must contain documentation to substantiate the answers on an incontinence certificate of medical necessity. A copy of the signed incontinence certificate of medical necessity must be maintained in the recipient’s medical record. (r) A provider enrolled under 7 AAC 105.210 as a durable medical equipment provider may not make unsolicited contact with a recipient of medical assistance under 7 AAC 105 — 7 AAC 160 for the purpose of marketing the provider’s products or services. (s) The department will only pay a claim for durable medical equipment, medical supplies, or related items and services under (a)(2) of this section if the prescribing physician, physician assistant, or advanced practice registered nurse provides a face-to-face examination of the recipient not more than six months before the beginning of services as defined in 42 C.F.R. 440.70 and 42 C.F.R. 410.38. The face-to-face examination must be related to the primary reason that the recipient requires the durable medical equipment, medical supplies, or related items and services. (t) A prescription order for durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, and related items and services must contain the

(1) recipient’s name and date of birth;

(2) item or service being prescribed;

(3) diagnosis;