Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.15 - Inpatient Non-Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Items and services for which there is no
			 legal obligation to pay -- Free services are excluded from coverage, (e.g.,
			 chest x-rays provided without charge by health organizations).
(2) Items and Services which are required as
			 a result of war -- Those required as a result or act of war, occurring after
			 the effective date of the patient's current coverage are not covered.
(3) Personal comfort items, such as radio,
			 television, telephones, beauty and barber services, which do not contribute
			 meaningfully to the treatment of an illness or injury or the functioning of a
			 malformed body member are not covered.
(4) Routine physical check-ups required by
			 third parties, such as insurance companies, business establishments or other
			 government agencies are not covered.
(5) Braces, orthopedic shoes, corrective
			 shoes, or other supportive devices for the feet are not covered.
(6) Custodial care or sitters are not
			 covered.
(7) Cosmetic surgery or
			 expenses in connection with such surgery are not covered. Cosmetic surgery
			 includes any surgical procedure directed at improving appearance, except when
			 required for the prompt repair of accidental injury or for the improvement of
			 the function of a malformed body member. For example, this exclusion does not
			 apply to surgery in connection with treatment of severe burns or repair of the
			 face following a serious automobile accident, nor to surgery for therapeutic
			 service, which coincidentally also serves some cosmetic purpose.
(8) Items and services to the extent that
			 payment has been made, or can reasonably be expected to be made under a
			 Workman's Compensation Law, or plan of the United States, or a state may not be
			 paid for by Medicaid.
(9) Inpatient
			 hospitalization for routine diagnostic evaluations that could be satisfactorily
			 performed in the outpatient department of the hospital, or in a physician's
			 office or appropriate clinic, is not covered.
(10) Psychological evaluations and testing
			 and psychiatric evaluations are not covered by Medicaid except where actually
			 performed by a physician in person.
(11) Speech therapy is not covered by
			 Medicaid unless actually performed by a physician in person.
(12) Reserved Bed Charges -- There is no
			 provision under the Alabama Medicaid Program for payment of reserved inpatient
			 hospital beds for patients on a pass for a day or more.
(13) Inpatient services provided specifically
			 for a procedure that requires prior approval is not covered unless prior
			 authorization from Medicaid for the procedure has been obtained by the
			 recipient's physician. In the event that the recipient is receiving other
			 services which require inpatient care at the time the procedure is performed,
			 any charges directly related to the procedure will be non-covered and subject
			 to recoupment. Additionally, all admissions must meet the Adult and Pediatric
			 Inpatient Care Criteria.
Author:
Lynn Sharp, Associate Director, Policy
				  Development Unit
Statutory Authority:
State Plan, Attachment
				  3.1A, pp. 1, 1.1; Title XIX, Social Security Act; 42 C.F.R.
				  §§405.310, 405.311, 405.314, 405.316.