reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.18 - Reimbursement For NET

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Reimbursement for transportation services is furnished through an Electronic
			 Benefit Transfer System (EBT) process wherein the recipient uses the
			 reimbursement to purchase transportation. Non-emergency ambulance
			 transportation is reimbursed fee for service.
(2) A tiered fee for transportation payment
			 structure is utilized based upon factors such as: mileage; client's physical,
			 mental or medical condition; whether the recipient is ambulatory or recumbent;
			 prevailing rates in the region; availability of transportation resources; level
			 of appropriate transportation required; and whether they are transported by a
			 family member, commercial carrier, or ambulance transporter.
Author:
Dorothy Powell, Associate Director,
				  Non-Emergency Transportation Program
Statutory Authority:
State Plan;
				  42 C.F.R. §
											431.53; Title XIX, Social Security
				  Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.19 - Administration Of The NET Program

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Alabama Medicaid Agency staff,
			 including Regional NET Coordinators and Central Office staff, serve as the
			 point of contact and assist with scheduling the least expensive appropriate NET
			 on a statewide basis. Recipients must contact the Agency to request
			 transportation assistance five days prior to the needed transportation or
			 within 24 hours after urgent care appointments. The Alabama Medicaid Agency
			 arranges necessary non-emergency transportation services for Medicaid
			 recipients. The responsibilities of the NET Program include, but are not
			 limited to, the following:
(a) Determine
			 availability of free transportation; this includes recipient's vehicle,
			 transportation by relative or friend or volunteer services. Medicaid
			 reimbursements are not awarded if recipient has access to free transportation,
			 except in the case of evident hardship.
(b) Determine mileage reimbursement for
			 recipient's vehicle or friend, relative or volunteer driver.
(c) Determine evident hardship.
(d) Verify eligibility; no reimbursement is
			 available for transportation to/from non-covered medical services.
(e) Verify scheduled medical
			 appointment.
(f) Determine the
			 least costly appropriate means of transportation services.
(g) Assign prior authorization
			 number
(h) Coordinate in-state and
			 out-of-state commercial bus, train, or air transportation; Approve the use of
			 commercial buses, trains or airplanes for in-state and out-of-state use for
			 Medicaid recipients.
(i) The
			 Alabama Medicaid Agency may issue a travel reimbursement through Electronic
			 Benefit Transfer (EBT) for the cost of fare for recipients who are able to ride
			 public transportation to medical services; public transportation should be
			 utilized whenever possible; before other modes of more expensive transportation
			 are authorized, there should be a determination that public transportation
			 cannot meet the recipient's needs.
(j) Issue reimbursements to the recipient or
			 redirect the reimbursement on behalf of the recipient to an address determined
			 to be more appropriate than the address on file
(k) Compile information on all certified and
			 licensed transporters.
(l) Complete
			 retrospective utilization review of transportation reimbursements
			 issued.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.20 - NET Escorts

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An escort
			 is defined as an individual, other than an employee of a Transporter, whose
			 presence is required to assist a recipient during transport and while at the
			 place of treatment. An escort is typically a relative, guardian, or volunteer.
			 Only one escort is covered per recipient in need and there must exist an
			 identifiable need for the escort. Escort services are utilized in-state or
			 out-of-state for recipients over 21 years of age only when a physician's
			 statement documents that an escort is required because the recipient is blind,
			 deaf, intellectually disabled, or mentally ill or physically handicapped to
			 such a degree personal assistance is necessary.
(2) Escorts are allowed for recipients under
			 the age of 21.
(3) The Alabama
			 Medicaid Agency must obtain a medical certification statement from the
			 individual requesting an escort for recipients age 21 and over before
			 reimbursement can be made. The certification must document that the recipient
			 is physically or mentally challenged, such as:
(a) blind;
(b) deaf;
(c) intellectually disabled;
(d) mentally ill; or
(e) physically handicapped to such a degree
			 that personal assistance is necessary.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.21 - Scope Of NET Service

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 NET reimbursements will be issued for transportation costs to and from covered
			 necessary medical services for which the recipient has benefits available as
			 defined at
			 42 CFR
			 440.210 including Early and Periodic
			 Screening, Diagnosis, and Treatment (EPSDT), inpatient hospital services,
			 outpatient hospital services, Federally Qualified Health Center (FQHC), rural
			 health clinic services, laboratory and x-ray services, breast and cervical
			 cancer services, physician services, medical and surgical services of a
			 dentist, medical equipment (e.g. orthotic and prosthetic), and pregnancy/family
			 planning services.
Author:
Dorothy Powell, Associate Director,
				  Non-Emergency Transportation Program
Statutory Authority:
State Plan;
				  42 C.F.R. §
											431.53; Title XIX, Social Security
				  Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.22 - Modes Of NET

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Net
			 services may be provided by one or more of the modes listed below when the
			 recipient's medical care is necessary and the recipient has no other
			 transportation resources. The least costly mode of transportation appropriate
			 to the needs of the recipient must be used. This section includes all services
			 covered by the NET Program:
(a) Automobile
			 (volunteer driver); multiple passenger transportation is encouraged. Volunteer
			 drivers can be reimbursed from the recipient's home (or place of admission or
			 discharge) and return, unless Medicaid determines paying for additional mileage
			 is the most economical transportation;
(b) Transportation provided by relatives or
			 individuals living in the same household with the Medicaid recipient;
(c) Transportation provided in the Medicaid
			 recipient's vehicle or relative's vehicle;
(d) minibus services;
(e) wheelchair vans services. Escorts are
			 allowed for wheelchair vans when prior approved by the Alabama Medicaid
			 Agency;
(f) bus (commercial or city
			 transit); this service may be provided in-state or out-of-state;
(g) airplane transportation will be
			 reimbursed for in-state or out-of-state service;
(h) train service may be provided in-state or
			 out-of-state;
(i)
			 ambulance.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.23 - NET Service Limitations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A maximum of one round trip may be
			 reimbursed per date of service per recipient, without prior authorization
			 exception.
Author:
Dorothy Powell, Associate Director,
				  Non-Emergency Transportation Program
Statutory Authority:
State Plan;
				  42 C.F.R. §
											431.53; Title XIX, Social Security
				  Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.24 - Non-Covered NET Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) When
			 appropriate free transportation is available.
(2) any travel when the Medicaid recipient is
			 not an occupant of the vehicle unless that would be the most economical
			 transportation available;
(3) meals
			 and lodging for volunteer drivers;
(4) the use of supplies such as oxygen,
			 intravenous fluids, etc.;
(5)
			 transportation for any services other than those covered by Medicaid;
(6) transportation provided after the death
			 of a Medicaid recipient;
(7)
			 minibus or wheelchair van travel outside a 30-mile radius of the state
			 boundary;
(8) services for which
			 prior approval is required but not obtained; and
(9) services are not medically necessary or
			 which are not provided in compliance with the provision of this
			 chapter.
Author:
Dorothy Powell, Associate Director,
				  Non-Emergency Transportation Program
Statutory Authority:
State Plan;
				  42 C.F.R. §
											431.53; Title XIX, Social Security
				  Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.25 - NET Provider And Driver Requirements - Exclusions

Current through Register Vol. 42, No. 9, June 28, 2024
The Medicaid Coverage of Certain Medical Transportation under
				the Consolidated Appropriations Act, 2021 (Public
				Law 116-260) established provider and driver
				minimum requirements for participation in NET, excluding any public transit
				authority. Provider(s) and driver(s) must adhere to the following:
(1) Exclusions
(a) Provider(s) and individual driver(s) must
			 not be excluded from participation in any federal health care programs (as
			 defined in section 1128B(f) of the Act).
(b) Provider(s) and individual driver(s) must
			 not appear on the Inspector General of the Department of Health and Human
			 Services exclusion list.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-19 - HEARING SERVICES › Section 560-X-19-.01 - Hearing Services - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Audiological function tests and hearing
			 aids are limited to Medicaid eligible individuals who are eligible for
			 treatment under the Early and Periodic Screening, Diagnosis and Treatment
			 (EPSDT) Program. Hearing aids are provided through hearing aid dealers who are
			 contracted to participate in the Alabama Medicaid Hearing Aid Program.
An eligible individual with hearing problems may be referred to
				a private physician or to Crippled Children's Service for medical evaluation.
				Audiological function tests must be referred by a physician before
				testing.
(2) Medical
			 Examination:
(a) A hearing aid will not be
			 approved for any Medicaid eligible recipient prior to a medical examination and
			 recommendation for a hearing evaluation by a licensed physician, within sixty
			 (60) days of the time of hearing aid fitting. This is mandatory.
(b) The medical examination should, if
			 possible, be given by a physician specializing in diseases of the ear. If a
			 physician of this type is not available or accessible, referral may be made to
			 Crippled Children Service for otological evaluation, medical clearance and
			 medical approval for the use of earmolds.
(c) Children under six (6) years of age shall
			 be examined by an otologist or otolaryngologist before an aid is
			 fitted.
(d) The examining physician
			 referring the patient to a hearing aid dealer will be required to furnish the
			 dealer with appropriate medical evaluation statements and recommendations,
			 according to program requirements.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-19 - HEARING SERVICES › Section 560-X-19-.02 - Participation And Enrollment Requirements

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Only in-state and borderline out-of-state
			 (within 30-mile radius of state line) audiology and hearing aid providers who
			 meet enrollment requirements are eligible to participate in the Alabama
			 Medicaid program.
Audiology providers
: Must hold a valid
				current state license issued by the state in which they practice. Since
				licenses are reviewed annually, Medicaid will review reference sources such as
				the Board of Examiners for Speech Pathology and Audiology for determining an
				audiologist's professional qualifications.
Medicaid's fiscal agent is responsible for enrollment of
				audiologists. Licensed audiologists desiring to participate in the Alabama
				Medicaid Program should furnish the following information in a written
				enrollment request to Medicaid's Fiscal Agent.
(a) Name
(b) Address
(c) Specialty provider type
(d) Social Security Number
(e) Tax ID Number
(f) Copy of current State license
Hearing Aid Dealers - must hold a valid current license issued
				by the Alabama Board of Hearing Aid Dealers, as issued by the state in which
				the business is located. Licensed hearing aid dealers desiring to participate
				in the Alabama Medicaid Program are required to enter into a contractual
				agreement with the Alabama Medicaid Agency. The dealer should request a
				contract agreement from the Associate Director of the Hearing Services Program,
				Alabama Medicaid Agency.
Author:
Carol Akin, Associate Director,
				Clinic/Ancillary Services
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-19 - HEARING SERVICES › Section 560-X-19-.03 - Billing Procedures And Claims Payment

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Audiologists and hearing aid dealers
			 should refer to Rule
			 560-X-1-.17, Chapter one,
			 Administrative Code, for provider billing instructions.
(2) Claim forms and billing instructions will
			 be furnished to participating providers by Medicaid's fiscal agent.
(3) An audiologist employed by a physician
			 cannot file a claim for the same services billed by that physician for the same
			 patient, on the same date of service.
(4) Providers may bill an Alabama Medicaid
			 recipient only when the recipient has exhausted all of his/her allowed Medicaid
			 benefits or when the service rendered is a non-covered service.
Author:
Statutory Authority:
State Plan; 42 C.F.R.
				  §§401,
et
seq
.;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-20 - THIRD PARTY › Section 560-X-20-.01 - Third Party Program

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 General.
(a) The purpose of the Third Party
			 Division of Alabama Medicaid Agency is to fulfill the requirements pertaining
			 to third party liability and to ensure that Medicaid is the payer of last
			 resort.
(b) In general third party
			 resources are primary to Medicaid.
(c) Federal law requires that state Medicaid
			 agencies take all reasonable measures to identify third party resources which
			 may have legal/fiscal/contractual liability as a result of medical assistance
			 furnished to a Medicaid recipient.
(d) Where third party liability is known or
			 reasonably expected, the Medicaid Agency ensures that Providers collect third
			 party resources prior to filing Medicaid.
(e) Where Medicaid payment has not been
			 reduced by third party benefits, the Medicaid Agency is required to take
			 reasonable measures to obtain reimbursement from third parties for the cost of
			 medical assistance furnished to Medicaid recipients to the extent that the
			 third party may have legal/fiscal/contractual liability. This may be done
			 through post payment billing to the third party or through recoupment of
			 Medicaid payment from the provider who must then file with the primary
			 payor.
(f) Claims for services
			 which are filed with Medicaid and paid in full or in part by a third party will
			 be applied against program benefit limitations.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-20 - THIRD PARTY › Section 560-X-20-.02 - Third Party Cost Avoidance And Recovery

Current through Register Vol. 42, No. 9, June 28, 2024
(1) General.
(a) All providers must file claims with a
			 third party as specified by this rule.
(b) Providers should not file with Medicaid
			 until the third party responds with a payment or denial. Exceptions: Providers
			 may file Medicaid and Medicare simultaneously if the Medicare intermediary
			 crosses over claims to the Medicaid fiscal agent. Providers may also file
			 Medicaid prior to actual payment being received from a third party when the
			 benefit is paid on a "set fee per day basis"; however, the provider must
			 indicate the amount to be paid by the third party on the Medicaid claim.
(c) Providers must file claims
			 with a primary third party within sufficient time for the third party to make
			 payment. If the provider has difficulty obtaining a response from the third
			 party or with the processing of Medicaid claims due to third party procedures,
			 the provider should contact the Third Party Division, Alabama Medicaid
			 Agency.
(d) An aged, outdated claim
			 which is timely submitted to Medicare or another third party must be received
			 by the fiscal agent within one hundred twenty (120) days of the notice of the
			 disposition of such claim to the provider.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-20 - THIRD PARTY › Section 560-X-20-.03 - Identification Of Third Party Resources

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Claim - All providers are required to
			 question Medicaid recipients to obtain information about third party resources
			 which may pay for medical services provided to the recipient. All providers
			 must complete third party fields on the Medicaid claim as required in the
			 Alabama Medicaid Provider billing Manual.
(2) Refunds - All third party payments must
			 be applied toward services for which payment was made. These payments may not
			 be applied against other unpaid accounts. If providers receive duplicate
			 payments from a third party and Medicaid, all duplicate party payments must be
			 refunded within 60 days by:
(a) Sending a
			 refund of payment to the Third Party Division, Medicaid; or
(b) Requesting an adjustment of Medicaid
			 payment via Medicaid's fiscal agent.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-20 - THIRD PARTY › Section 560-X-20-.04 - Third Party Payments/Denials

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Third Party Payments other than Medicare
(a) Third Party payments must be applied to
			 the services for which the third party paid.
(b) Providers receiving a third party payment
			 prior to filing Medicaid must document in the appropriate field on the claim
			 the amount of the third party payment.
(c) Providers receiving a third party payment
			 after Medicaid is filed must within 60 days of receiving duplicate payment:
1. Refund the lessor of the insurance paid
			 amount or the Medicaid paid amount to the Third Party Division, Alabama
			 Medicaid Agency; or
2. Submit an
			 adjustment request to the Medicaid Fiscal Agent that resolves the duplicate
			 payment.
(d) If the
			 third party pays the recipient or source other than the provider, the provider
			 is responsible for obtaining the third party payment prior to filing Medicaid.
			 If the Third Party pays a source other than Medicaid, as a result of
			 information released by the Provider and Medicaid has paid the Provider,
			 Medicaid may recoup its payment.
(e) If the provider accepts a patient with a
			 third party resource and Medicaid, the provider cannot bill the patient for
			 Medicaid covered services if:
1. The third
			 party pays more than Medicaid allows and Medicaid zero pays the
			 claim.
2. Medicaid denies a claim
			 because a third party resource exists and recipient has provided third party
			 information in a timely manner.
(f) A provider may bill a Medicaid patient if
			 Medicaid denies a claim because of available third party benefits and the
			 provider cannot obtain sufficient information needed to file a third party
			 claim from either the recipient, AVRS, MACSAS or the Medicaid Agency.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-20 - THIRD PARTY › Section 560-X-20-.05 - Release Of Information - All Providers

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Requests for copies of recipient's
			 medical bills, histories, and statements provide Medicaid with third party
			 resource leads. Therefore, information that is released by providers and that
			 pertains to the care and treatment of a Medicaid recipient must be documented
			 and reported to Medicaid in the following manner. Failure on the part of the
			 provider to meet these requirements may result in recoupment of Medicaid
			 payment.
(a) Claims submitted by the provider
			 to a health plan or other entity for the purpose of the provider obtaining
			 payment must include an assignment of benefits to the provider.
(b) Billing statements, itemized billings,
			 and medical records released for reasons other than the provider obtaining
			 payment must include the following statement clearly printed on the documents
			 released:
Medicaid has a subrogation/assignment interest. Contact
			 Medicaid.
(c) Complete a
			 "Request for Medical Records" form to identify the requestor and reason for the
			 request for medical records information. A "Request for Medical Records" can be
			 obtained from the Alabama Medicaid Agency website and submitted to the address
			 or fax # listed on the form.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-20 - THIRD PARTY › Section 560-X-20-.06 - Fiscal Agent Responsibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Medicaid's fiscal agent is responsible
			 for monitoring all claims for possible third party liability and utilizing
			 information on the claim to identify potential Third Party liability. The
			 fiscal agent will utilize Medicare coverage dates, the Commercial TPL policy
			 file and Medicare Advantage enrollment dates to ensure that Medicaid properly
			 processes claims as the payer of last resort.
(2) The fiscal agent is responsible for
			 editing claims for third party coverage in accordance with State requirements
			 to ensure that claims are either cost avoided, recouped from the provider, or
			 identified for post payment billing to third party payers.
(3) The fiscal agent is responsible for
			 retroactively identifying third party liability, including Medicare, and either
			 cost avoiding covered claims, recouping Medicaid payment from the provider or
			 producing post payment billings to an insurance carrier to obtain reimbursement
			 for Medicaid paid claims in accordance with State and Federal
			 requirements.
Author:
Wanda Wright, Administrator, Third Party
				  Liability
Statutory Authority:
Code of Ala.
				  1975
, §
										22-6-6, 42 CFR §§432 and
				  433; Section 1902(a)(25), Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-20 - THIRD PARTY › Section 560-X-20-.07 - Recipient Responsibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 The Alabama Medicaid Agency by statute is subrogated to the rights of a
			 Medicaid recipient against any third party arising out of injury, disease, or
			 sickness. Medicaid recipients are required to assist and cooperate fully with
			 Alabama Medicaid Agency in its efforts to secure such rights including the
			 requirement to:
(a) Notify Alabama Medicaid
			 Agency within ten days of filing suit against a third party;
(b) Notify Alabama Medicaid Agency, Third
			 Party Division, prior to entering any settlement with a third party;
(c) Immediately pay to Alabama Medicaid
			 Agency all funds received from any third party to the extent necessary to
			 satisfy the subrogation rights of the State of Alabama;
(d) Disclose information regarding health
			 insurance or other third party resources when applying for Medicaid;
(e) Notify providers of medical care of
			 health and casualty coverage and other third party resources when requesting
			 medical care. Recipients are required to comply with their primary plans
			 guidelines by utilizing network providers and obtaining prior authorizations
			 when required.
(f) Notify Alabama
			 Medicaid Agency of any health insurance obtained after becoming eligible for
			 Medicaid;
(g) Notify Alabama
			 Medicaid Agency, Third Party Division, of any casualty/liability insurance
			 which may cover medical treatment received due to an injury;
(h) Execute and deliver all instruments and
			 papers needed by Alabama Medicaid Agency in pursuit of its subrogation
			 claim.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-20 - THIRD PARTY › Section 560-X-20-.08 - Payment Of Health Insurance Premiums

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Alabama Medicaid Agency may pay
			 health insurance premiums of certain Medicaid eligibles or recipients when the
			 agency determines that payment of the premium would be cost effective. The
			 primary objective of paying certain health insurance premiums is to reduce
			 Medicaid expenditures by enrolling Medicaid eligibles in or continuing existing
			 health insurance coverage so that Medicaid becomes a secondary payor.
(2) Cost effectiveness is defined as meaning
			 the expenditure of Medicaid funds for a set of services is likely to be greater
			 than the cost of paying the health insurance premium. Criteria for determining
			 cost effectiveness will be determined by the Alabama Medicaid Agency.
Author:
Kay Keeshan
Previous Chapter 560-X-20 (Rules
				  560-X-20-.01 through
				  560-X-20-.11) filed September 30, 1982. Repealed and new Chapter (Rules
				  560-X-20-.01 through
				  560-X-20-.07) adopted in lieu
				  thereof: Filed February 4, 1985.
Statutory Authority:
42 CFR §§ 432,
				  433; § 1902(a)(25) Social Security Act; Consolidated Omnibus
				  Reconciliation Act of 1985; § 4402 Omnibus Reconciliation Act of
				  1990.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-21 - NURSE MIDWIFE PROGRAM › Section 560-X-21-.01 - Legal Authority For The Nurse Midwife Program

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Alabama Law provides rules under which
			 properly trained nurses can be licensed to practice the profession of Nurse
			 Midwifery. (
Code of Ala. 1975
, §§
								34-19-2,
et
seq
.)
(2) Federal Law [Title XIX, Sections
			 1905(a)(17) and (m)] requires that the Medicaid Program in each state include
			 the services of nurse midwives as a mandated service.
(3) These regulations state the conditions
			 under which the services of nurse midwives are covered by the Medical
			 Assistance Program of the Alabama Medicaid Agency.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§440.210,
				  440.165,
				  441.220, and
				  441.21.
Code of Ala. 1975
, §§
										34-19-2,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-21 - NURSE MIDWIFE PROGRAM › Section 560-X-21-.02 - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Providers in
			 this program are limited to persons who are licensed as "Registered Nurse" and
			 who are also licensed as "Certified Nurse Midwife."
(2) Nurse Midwifery practice is defined as
			 the management of care for normal healthy women and their babies in the areas
			 of prenatal; labor and delivery; postpartum care; well-woman gynecology,
			 including family planning services; and normal newborn care.
(3) The practice of Nurse Midwifery must be
			 done under appropriate physician supervision.
(4) The services provided by nurse midwives
			 must be within the scope of practice authorized by state law and regulations.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§440.165, and
				  441.21.
Code of Ala. 1975
, §§
										34-19-2,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-21 - NURSE MIDWIFE PROGRAM › Section 560-X-21-.03 - Provider Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In
			 order to participate in the program a nurse midwife must submit a completed
			 application form along with a copy of current registered nurse and nurse
			 midwife licensure, plus copy of the written signed agreement between the nurse
			 midwife and the physician consultant. If the application is approved, Medicaid
			 will offer the applicant a one year renewable contract.
(2) Only in-state and border line
			 out-of-state (within a 30-mile radius of Alabama's state line) providers who
			 meet enrollment requirements are eligible to participate in the Alabama
			 Medicaid Program.
(3) Nurse
			 Midwives who want to participate in the Medicaid program should contact the
			 Medicaid Agency for an enrollment application. Send the request to:
Administrator of Nurse Midwife Program
Alabama Medicaid Agency
501 Dexter Avenue
P. O. Box 5624
Montgomery, Alabama 36103-5624
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
seq
., 440.165, 441.21;
Code of Ala.
				  1975
, §§
										34-19-2,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-21 - NURSE MIDWIFE PROGRAM › Section 560-X-21-.04 - Reimbursement

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Nurse midwives
			 may submit claims and be reimbursed only for those procedure codes authorized
			 by Medicaid policy. Claims should be submitted on a Health Insurance (HCFA
			 1500) Claim Form.
(2) The nurse
			 midwife agrees when billing Medicaid for a service that the midwife will accept
			 as payment in full, the amount paid by Medicaid for the services and that no
			 additional charges will be made.
(3) Conditional collections from patients,
			 made before Medicaid pays, to be refunded after Medicaid reimbursement for the
			 service, are not permissible.
(4) A
			 hospital-based nurse midwife who is employed by and paid by a hospital may not
			 bill Medicaid for services performed therein and for which the hospital is
			 reimbursed. A nurse midwife who is not employed by and paid by a hospital may
			 bill Medicaid using a Health Insurance (HCFA 1500) Claim Form. To prevent
			 double payment, the nurse midwife having a Medicaid provider number(s) shall
			 inform the Alabama Medicaid Agency of the name of the hospital(s) with whom
			 employed, regardless of regularity and frequency.
Author:
Glen A. Smythe
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§440.165,
				  440.210,
				  440.220,
				  441.21;
Code of Ala. 1975
, §§
										34-19-2,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-21 - NURSE MIDWIFE PROGRAM › Section 560-X-21-.05 - Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 maternity services normally provided in maternity cases include antepartum
			 care, delivery, and postpartum care. When a nurse midwife provides total
			 obstetrical care, the procedure code which shall be filed on the claim form is
			 the code for all inclusive "global" care. The indicated date of service on
			 "global" claims should be the date of delivery. If a woman is pregnant at the
			 time she becomes eligible for Medicaid benefits, only those services provided
			 during the time she is eligible will be covered. When a nurse midwife provides
			 eight (8) or more prenatal visits, performs the delivery, and provides
			 postpartum care, he/she shall use a "global" obstetrical code in billing the
			 services. If a nurse midwife submits a "global" code for maternity services,
			 the visits covered by this code are not counted against the recipient's limit
			 of physician office visits per calendar year. For purposes of "global"
			 obstetrical billing, services rendered by members of a group practice are to be
			 considered as services rendered by a single provider.
(a) Antepartum care includes all usual
			 prenatal services such as initial office visit, at which time the pregnancy is
			 diagnosed, initial and subsequent histories, physical examinations, blood
			 pressure recordings, fetal heart tones, maternity counseling, etc.; therefore,
			 additional claims for routine services shall not be filed. Antepartum care also
			 includes routine lab work (i.e.; hemoglobin, hematocrit, and chemical
			 urinalysis); therefore, additional claims for routine lab work should not be
			 filed.
1. In order to bill for Antepartum Care
			 Only services, nurse midwife providers must utilize the antepartum procedure
			 codes when billing for the services. Antepartum Care Only services do not count
			 against the recipient's annual office visit benefit limits. When less than four
			 antepartum visits are provided, the nurse midwife will use office visit
			 procedure codes to bill for the services. The office visit procedure codes will
			 be counted against the recipient's annual office visit benefit limit.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-21 - NURSE MIDWIFE PROGRAM › Section 560-X-21-.06 - Required Written Records

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 When a patient is accepted for monthly services, the midwife's care must
			 include plans for a delivery to be accomplished in a licensed hospital. In an
			 emergency, delivery may be accomplished elsewhere. The plans need not be
			 submitted to Medicaid but the midwife's file should contain written evidence
			 that such plans existed for each patient accepted for global care.
(2) All nurse midwife services must be
			 rendered under appropriate physician supervision. The physician may not bill
			 for these supervisory services. The written records that each midwife keeps
			 should include records naming the physician(s) with whom she works, and stating
			 the working arrangement with the physician. The statement of the working
			 arrangement need not be a formal contract, but it must contain the signature of
			 both parties and must show the date on which it was signed.
(3) A complete medical record shall be
			 maintained for each recipient for whom the nurse midwife provides services.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§440.165,
				  440.210,
				  440.220,
				  441.21;
Code of Ala. 1975
, §§
										34-19-2,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-21 - NURSE MIDWIFE PROGRAM › Section 560-X-21-.07 - Payments To Physicians

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 supervising physician may not bill for supervisory services. The physician can
			 bill Medicaid, however, if it becomes necessary for the physician to perform
			 the delivery or complete a delivery service for the nurse midwife. When the
			 physician bills the delivery only service, the midwife may bill antepartum care
			 or postpartum care, or both, depending on which service(s) the nurse midwife
			 performed. If the physician bills for delivery only including postpartum care,
			 the nurse midwife may bill only for the antepartum care provided.
(2) Sterilization at the time of delivery is
			 covered by Medicaid only if it is performed by the physician, and only if all
			 other Medicaid requirements for sterilization are met.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §441.21;
Code of Ala.
				  1975
, §§
										34-19-2,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-21 - NURSE MIDWIFE PROGRAM › Section 560-X-21-.08 - Third Party Requirements

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Nurse Midwives are required to identify
			 recipients who are covered by third party resources and to obtain payment from
			 those resources in accordance with Chapter 20 of the Medicaid Agency's
			 Administrative Code.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; §1902(a)(25); 42 C.F.R. §441 ;
Code
				  of Ala. 1975
, §§
										22-6-6,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-21 - NURSE MIDWIFE PROGRAM › Section 560-X-21-.09 - Billing Of Medicaid Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Refer to Chapter 1 of this Code for
			 general information regarding providers billing Medicaid recipients.
(2) Medicaid recipients are exempt from
			 co-payment requirements for maternity care and family planning
			 services.
(3) Co-pay requirements
			 apply to well-woman gynecological office services, except for those recipients
			 under the age of 18.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§447.15,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.01 - Nursing Facility Reimbursement - Preface

Current through Register Vol. 42, No. 9, June 28, 2024
This regulation states the Medicaid policy regarding nursing
				facility reimbursement and establishes the accepted procedures whereby
				reimbursement is made to nursing facility providers. Because of the length and
				complexity of this chapter, it has been divided into the following sections to
				facilitate its utilization.
Author:
Susan Mims
Statutory Authority:
Code of Ala.
				  1975
, §
										41-22-2.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.02 - Introduction

Current through Register Vol. 42, No. 9, June 28, 2024
(1) This chapter of
			 the Alabama Medicaid Regulations has been promulgated by the Alabama Medicaid
			 Agency, Medicaid, for the guidance of providers of Medicaid nursing facility
			 care. This chapter is applicable to those providers categorized as NF, NF/IMD,
			 and NF/IDD. It does not apply to those providers categorized as
			 ICF/MR.
(2) The Alabama Medicaid
			 Program is administered by Medicaid under the direction of the Governor's
			 office. Reimbursement principles for nursing facilities are outlined in the
			 following sections of this chapter. These principles, hereinafter referred to
			 as "Medicaid Reimbursement Principles," are a combination of generally accepted
			 accounting principles, principles included in the State Plan, Medicare (Title
			 XVIII) Principles of Reimbursement, and principles and procedures promulgated
			 by Medicaid to provide reimbursement of provider costs which must be incurred
			 by efficiently and economically operated nursing facilities. These principles
			 are not intended to be all inclusive, and additions, deletions, and changes to
			 them will be made by Medicaid on an annual basis, or as required. Providers are
			 urged to familiarize themselves fully with the following information, as cost
			 reports must be submitted to Medicaid in compliance with this
			 regulation.
(3) If this regulation
			 is silent on a given point, Medicaid will
normally
rely on Medicare (Title XVIII) Principles of Retrospective Reimbursement and,
			 in the event such Medicare Principles provide no guidance, Medicaid may impose
			 other reasonability tests. The tests include, but are not limited to, such
			 tests as:
(a) Does the cost as reported
			 comply with generally accepted accounting principles?
(b) Is the cost reasonable on its own
			 merit?
(c) How does the cost
			 compare with that submitted by similarly sized homes furnishing like category
			 of care?
(d) Is the cost related to
			 patient care and necessary to the operations of a nursing facility?
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.04 - Nurses Continuing Education

Current through Register Vol. 42, No. 9, June 28, 2024
Mandated Continuing Education Units for nurses and inservice
				training for nurse aides will be an allowable cost in the direct cost center if
				it was received in the State of Alabama. All other education cost will be
				accounted for in the operating cost center.
Author:
Bob Murphy
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act,
				  42 C.F.R. §
											447.200 - .272,
et
seq
.
Ed Note:
Previous Rule 560-X-22-.04 entitled
Budget Variance
effective October 1, 1982.
Repealed by
				  amendment of Chapter 560-X-22
effective October 1,
				  1990.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.05 - Medicaid Per Diem Rate Computation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Medicaid per diem rate will be
			 determined under reimbursement methodology contained in this chapter. (See Rule
			 560-X-22-.06.) The rates will be
			 based on the cost data contained in cost reports (normally covering the period
			 July 1 through June 30th). In order to allow adequate time for a provider to
			 prepare and submit the cost report and for Medicaid to compute a new rate, each
			 provider will be paid an interim per diem rate. This interim rate will cover
			 the period July 1 through December 31. The interim rate shall be the lower of
			 the latest allowable computed rate or the ceiling rate per day. The allowable
			 rate per day shall be trended by the Alabama Medicaid trend factor. [See Rule
			 560-X-22-.07(4)]
			 Providers will be paid a weighted per diem rate for the portion of the fiscal
			 year remaining after the provider's new rates are established. The weighted per
			 diem rate will be determined as outlined below:
(2) To calculate the weighted per diem rate:
			 Multiply the allowable per diem rates times twelve. Deduct from that product
			 the interim per diem rate multiplied by the number of months paid. Divide the
			 remainder by the number of months remaining in the fiscal year.
(a) Example 1. Provider's interim rate has
			 been in effect for five (5) months. Provider's weighted rate will be in effect
			 for seven (7) months:
Allowable per diem rate for the year $50.00
Interim rate paid $48.00
Allowable per diem rate multiplied by 12 = $50.00 x 12
				$600.00
Deduct
interim per diem rate
				multiplied by number of months paid = $48.00 x 5 = $240.00
Remainder = $360.00
Divide the remainder by the number of remaining months in the
				fiscal year = $360.00 - 7
= Weighted per diem rate = $51.43
(b) Example 2. Provider's interim rate has
			 been in effect for six (6) months. Provider's weighted rate will be in effect
			 for six (6) months:
Allowable per diem rate for the year $50.00
Interim rate paid $48.00
Allowable per diem rate multiplied by 12 = $50.00 x 12
				$600.00
Deduct interim per diem rate multiplied by number of months
				paid = $48.00 x 6 = $288.00
Remainder = $312.00
Divide the remainder by the number of remaining months in the
				fiscal year = $312.00 - 6 = Weighted per diem rate = $52.00
(c) Unapproved Beds. Capital expenditures
			 must be approved under the State Certificate of Need Program.
Authors:
Michael C. Murphy, Susan
				Mims
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.06 - Reimbursement Methodology

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All
			 nursing facilities will be grouped into three (3) functional categories:
(a) Nursing Facility (NF).
(b) Nursing Facility/Institution for Mental
			 Disease (NF/IMD).
(c) Nursing
			 Facility/Institution for the Developmentally Disabled (NF/IDD).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.07 - Medicaid Inflation Index

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 The Medicaid Inflation Index will be used in lieu of budgeting to adjust
			 certain actual allowable costs from one reporting period for the purpose of
			 computing the per diem rate payable for a subsequent reporting period and for
			 such other adjustments as may be specified in this chapter.
(2) The Medicaid Inflation Index shall be
			 based upon the economic indicators as published by Data Resources, Inc., (DRI)
			 for the Department of Health and Human Services. The indicators shall be the
			 Market Basket Index of Operating Costs - Skilled Nursing Facility, which are
			 published quarterly, whereas the Medicaid fiscal year for cost reporting and
			 rate setting purposes ends on June 30th. Therefore, the Medicaid Inflation
			 Index for a rate period will be the DRI Index for the twelve-month period
			 ending on the calendar quarter for which the index has been published or made
			 available at October 1st of each year.
(3) The Medicaid Inflation Index will be
			 established each October 1st for the current fiscal year based upon the
			 information then available to Medicaid and will not be adjusted again until the
			 next following October 1st, regardless of any later release of revised or
			 additional information relevant to the determination of the index.
(4) Interim Inflation Factor. The interim
			 rate shall be the lower of the latest allowable computed rate [Rule
			 560-X-22-.05(l)(b)]
			 or the ceiling rate per day. The applicable allowable rate per day shall be
			 trended by the Alabama Medicaid trend factor. The trend factor shall be the
			 National Forecast-Nursing Home Market Basket for the following fiscal year as
			 published by Data Resources, Inc. This forecast is published quarterly;
			 therefore, the latest forecast available at June 1st each year shall be
			 used.
Author:
Susan Mims
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42
				  C.F.R., §§
											447.200 - .272.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.08 - Patient Days

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A patient
			 day is incurred when any one of the following conditions have been met:
(a) Care is rendered to a patient in the
			 facility. This results when a patient is rendered services between the census
			 taking hour (12:00 midnight) on two (2) successive days. The following
			 procedure illustrates the proper method of determining the number of patient
			 days resulting from care rendered to patients in the facility, using the
			 midnight census method:
1. Number of patients
			 in the facility at midnight.
2.
			 Add/subtract patients admitted/discharged (including deaths) prior to midnight
			 of the following day (Exception - a patient admitted and discharged on the same
			 day counts as a patient day.) The provider may bill for the date of admission,
			 but not for the day of discharge.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-22 - NURSING FACILITY REIMBURSEMENT › Section 560-X-22-.09 - Staffing

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Providers are
			 expected to staff nursing care functions in accordance with state licensure
			 requirements.
(2) Staffing of each
			 functional area within each facility will be reviewed by Medicaid for
			 reasonableness.
(3) An adjustment
			 will be made to decrease allowable costs for facilities which are deemed to be
			 overstaffed in any particular functional area.
Author:
Susan Mims
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42
				  C.F.R. §§
											447.200 - .272,
et seq
.