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CMS has not issued a rate on the current quarter’s Medicare DMEPOS Fee Schedule as described in (b) of this section or for which the department has not established a rate and published the rate on the Alaska Medicaid DMEPOS Fee Schedules, Tables 1-5 through 1-9, adopted by reference in 7 AAC 160.900, or Alaska Medicaid DMEPOS Interim Fee Schedule, will be based on the submitted unaltered final purchase invoice price plus 35 percent, as follows, for claims submitted on or after June 2, 2019 and before the date the rate is established, until a rate is set by CMS or the department:

(1) if the median unaltered final purchase invoice price of the non-miscellaneous HCPCS item for the first 10 claims is less than $5,000, the final rate will be set at

(A) the median submitted unaltered final purchase invoice price of the first 10 claims plus 35 percent if the first 10 claims were paid to at least two different enrolled providers; or

(B) the median submitted unaltered final purchase invoice price of the number of claims paid, plus 35 percent after 15 claims are paid but have not been paid to at least two different enrolled providers;

(2) if the median unaltered final purchase invoice price of the non-miscellaneous HCPCS item for the first 10 claims is $5,000 or more, the final rate will be set at

(A) the median submitted unaltered final purchase invoice price plus 30 percent if the first 10 claims were paid to at least two different enrolled providers; or

(B) the median submitted unaltered final purchase invoice price of the number of claims paid, plus 30 percent after 15 claims are paid but have not been paid to at least two different enrolled providers;

(3) when applicable, the rental rates for a covered item non-priced, non-miscellaneous HCPCS code for which CMS or the department has not issued a permanent rate will be 10 percent of the rate set out in (1) of this subsection;

(4) all claims paid under this subsection must be submitted with an unaltered final purchase invoice, free of alteration described in (k) of this section; claims submitted without an unaltered final purchase invoice or with anything other than an unaltered final purchase invoice will be denied. (d) Payment rates for covered items submitted using a miscellaneous HCPCS code as defined in 7 AAC 120.399 for which CMS or the department has not issued a rate as described in (b) of this section will be paid, as follows, at the unaltered final purchase invoice price plus 20 percent, except when the covered item is a customized prosthetic or orthotic item manufactured under the oversight of and signed off by a certified professional described in 7 AAC 120.300(a)(2)(C):

(1) the department will not set a generic rate for the miscellaneous HCPCS code, but the department may set a rate based on a national product code or other product identifier and may require the unique identifier to be submitted on claims to facilitate payment;