reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-4 - PROGRAM INTEGRITY DIVISION › Section 560-X-4-.06 - Medicaid Eligibility Quality Control

Current through Register Vol. 42, No. 9, June 28, 2024
The Alabama Medicaid Agency Quality Control Unit is responsible
				for monitoring Medicaid eligibility correctness. Through its findings
				administrators may identify and eliminate or reduce dollar losses by effective
				corrective action in program operations.
(1) Quality Control shall select a monthly
			 random sample of Medicaid recipients from the computer maintained eligibility
			 file.
(2) The random sample shall
			 be reviewed for eligibility determination errors, policy application, and
			 administrative correctness.
(3)
			 Claims shall be collected on the sample to determine payment and error rate due
			 to eligibility determination errors.
(4) Information gathered from these reviews
			 shall provide the basis for corrective action to reduce erroneous Medicaid
			 payments.
(5) The Department of
			 Human Resources (DHR) has eligibility quality control responsibility for the
			 state supplementation segment of Medicaid eligibles.
(6) The total Medicaid payment error rate is
			 the amount of erroneous claims paid due to client ineligibility in the medical
			 assistance only (MAO), and state supplementation cases.
(7) The Agency shall participate in and
			 conduct Payment Error Rate Measurement (PERM) eligibility reviews once every
			 three-years to produce a national error rate.
(8) A sampling plan will be developed;
			 sampling universe identified with claims payment amounts for the sampled
			 cases.
(9) Information gathered
			 from these PERM reviews shall provide the basis for corrective action to reduce
			 erroneous Medicaid payments.
Author:
Jacqueline G. Thomas, Director, Program
				  Integrity Division
Statutory Authority:
State Plan; 42 C.F.R. Sec.
				  401, et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-5 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS 65 OR OVER › Section 560-X-5-.01 - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Inpatient
			 psychiatric services for recipients age 65 or over, are covered services when
			 provided:
(a) In a free-standing psychiatric
			 hospital exclusively for the treatment of persons age 65 or over with serious
			 mental illness (as defined in the Diagnostic and Statistical Manual of Mental
			 Disorders, Fourth Edition);
(b)
			 Under the direction of a geriatric psychiatrists;
(c) After the recipient reaches the age of
			 65; and
(d) To a patient remaining
			 in a facility for the course of the hospitalization.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-5 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS 65 OR OVER › Section 560-X-5-.02 - Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In order to
			 participate in the Title XIX Medicaid program and to receive Medicaid payment
			 for inpatient services for individuals 65 and older, a provider must meet the
			 following requirements:
(a) Be certified for
			 participation in the Medicare/Medicaid program;
(b) Be licensed as an Alabama free-standing
			 acute geriatric psychiatric hospital in accordance with current rules contained
			 in the Alabama Administrative Code Chapter 420-5-7. State hospitals that do not
			 require licensing as per state law are exempt from this provision (Alabama
			 Code, Section
			 22-50-1, et seq.);
(c) Be accredited by the Joint Commission on
			 Accreditation of Healthcare Organizations;
(d) Specialize in the care and treatment of
			 geriatric patients with serious mental illness;
(e) Have on staff at least one full-time
			 board certified geriatric psychiatrist/geriatrician; or a full-time board
			 certified adult psychiatrist with a minimum of 3 years' experience caring for
			 geriatric patients 65 or older.
(f)
			 Employ only staff who meet training/certification standards in the area of
			 adult psychiatry as defined by the State's mental health authority;
(g) Be recognized as a teaching hospital, and
			 affiliated with at least one four-year institution of higher education with a
			 multi-disciplinary approach to the care and treatment of geriatric patients
			 with serious mental illness;
(h)
			 Provide out-patient and community liaison services throughout the State of
			 Alabama directly or through contract with qualified providers;
(i) Be in compliance with Title VI and VII of
			 the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973,
			 the Age Discrimination Act of 1975, and the Americans with Disabilities
			 Act;
(j) Execute an Alabama
			 Medicaid Provider Agreement for participation in the Medicaid
			 program;
(k) Submit a written
			 description of an acceptable utilization review plan currently in effect;
(l) Submit a budget of cost for its
			 inpatient services for its initial cost reporting period, if a new provider;
			 and
(m) Be under the jurisdiction
			 of the State's mental health authority.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-5 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS 65 OR OVER › Section 560-X-5-.03 - Geriatric Inpatient Psychiatric Benefits

Current through Register Vol. 42, No. 9, June 28, 2024
(1) For purposes of this chapter, an
			 inpatient is a person, age 65 or over, who has been admitted to a freestanding
			 psychiatric facility specializing in the diagnosis, treatment and care of
			 geriatric patients occupying beds, for the purpose of maintaining or restoring
			 to the greatest possible degree of health and independent
			 functioning.
(2) The number of days
			 of care charged to a recipient or inpatient psychiatric service is always units
			 of full days. A day begins at midnight and ends 24 hours later. The midnight to
			 midnight method is used in reporting days of care for the recipient, even if
			 the facility uses a different definition of day for statistical or other
			 purposes.
(3) Medicaid
			 reimbursement is available for the day of admission, but not the day of
			 discharge.
(4) Therapeutic visits
			 away from the psychiatric facility to home, relatives or friends are authorized
			 if certified by the attending physician as medically necessary in the treatment
			 of the recipient.
(a) Therapeutic visits may
			 be authorized up to 14 days per admission if certified by the attending
			 physician as medically necessary in the treatment of the recipient. No part of
			 the time spent on any therapeutic leave may be billed to Medicaid.
(b) Return to inpatient status from
			 therapeutic visits exceeding 14 days per admission will be considered a
			 readmission with the required certification of need for treatment documented in
			 the patient's record.
(c)
			 Therapeutic visit records will be reviewed retrospectively by the Quality
			 Assurance Program at Medicaid. Providers that have received payments for
			 therapeutic visits will have funds recouped.
Author:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-5 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS 65 OR OVER › Section 560-X-5-.04 - Certification Of Need For Service

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Certification of need for services is a
			 determination which is made by a physician regarding the Medicaid recipient's
			 treatment needs for admission to the facility.
(2) The physician must certify for each
			 applicant or recipient that inpatient services in a mental hospital are or were
			 needed.
(3) The certification must
			 be made at the time of admission. No retroactive will be accepted.
(4) For individuals applying for Medicaid
			 while in the hospital, the certification must be made before Medicaid can
			 authorize payment.
(5) The
			 physician must complete the PSY-5 form which is the certification of need for
			 care. This form must be kept in the patient's record.
(6) The PSY-6 form, or acceptable equivalent
			 approved by Medicaid, which is the recertification of need for continued
			 inpatient services for each applicant or recipient, must be completed by a
			 physician, a physician assistant, or a nurse practitioner acting under the
			 supervision of a physician.
(7) The
			 PSY-6 form, or acceptable equivalent must be completed at least every 60 days
			 after initial certification. This form must be kept in the patient's
			 record.
(8) The physician must
			 complete an assessment note in the patient's record within 24 hours of a
			 patient's return from any leave status.
Author:
Statutory Authority:
42 C.F.R. Section 441,
				  Subpart D.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-5 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS 65 OR OVER › Section 560-X-5-.05 - Medical, Psychiatric, And Social Evaluation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Before admission to a psychiatric
			 facility or before authorization for payment, the attending physician,
			 psychiatrist, or staff physician must make a medical evaluation of each
			 individual's need for care in the facility. Appropriate professional personnel
			 must make a psychiatric and social evaluation.
(2) Each medical evaluation must include:
(a) Diagnosis;
(b) Summary of present medical
			 findings;
(c) Medical
			 history;
(d) Mental and physical
			 functional capacity;
(e) Prognosis;
			 and
(f) A recommendation by the
			 physician concerning:
1. Admission to the
			 psychiatric facility; or
2.
			 Continued care in the psychiatric facility for individuals who apply for
			 Medicaid while in the facility.
Author:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-5 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS 65 OR OVER › Section 560-X-5-.06 - Plan Of Care

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 attending physician or staff physician must establish a written plan of care
			 for each individual before admission to a mental hospital and before
			 authorization of payment.
(2) The
			 plan of care must include:
(a) Diagnosis,
			 symptoms or complaints indicating a need for admission to inpatient
			 care;
(b) Description of the
			 functional level of the patient;
(c) Treatment objectives;
(d) Orders for medication, treatments,
			 therapies, activities, restorative/rehabilitative services, diet, social
			 services and special procedures needed for health and safety of the patient;
			 and
(e) Continuing care plans that
			 include post-discharge plans and coordination of inpatient services with
			 partial discharge plans and related community services to ensure continuity of
			 care with the recipient's family and community service providers upon
			 discharge.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-5 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS 65 OR OVER › Section 560-X-5-.07 - Utilization Review (UR) Plan

Current through Register Vol. 42, No. 9, June 28, 2024
As a condition of participation in the Title XIX Medicaid
				program, each psychiatric facility shall:
(1) Have in effect a written UR Plan that
			 provides for review of each recipient's need for services that the facility
			 furnishes to him. This written UR Plan must meet the requirements under
			 42 C.F.R.
			 Section 456.201 through Section
			 456.245;
(2) Maintain recipient information required
			 for the UR Plan under
			 42 C.F.R. Section
			 456.211, which shall include the
			 certification of need for service and the plan of care; and
(3) Provide a copy of the UR Plan and any
			 subsequent revisions to Medicaid for review and approval.
Author:
Statutory Authority:
42 C.F.R.
				  Section 456.200 -
				  456.245.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-5 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS 65 OR OVER › Section 560-X-5-.08 - Payment

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Payment for
			 inpatient services provided by psychiatric facilities for individuals age 65
			 and older shall be the per diem rate established by Medicaid for the hospital,
			 which is based on the Medicaid cost report and all the requirements expressed
			 in Chapter 23 of the Alabama Medicaid Administrative Code. Patient liabilities,
			 if applicable, will be deducted from the per diem. The hospital will be
			 responsible for collecting the liability amount from the patient and/or his/her
			 sponsor. Providers should reference their billing manual for claim submission
			 procedures.
(2) Providers are
			 required to file a complete uniform Medicaid cost report for each fiscal year.
			 Two copies of this report must be received by Medicaid within three months
			 after the Medicaid cost report year-end.
(3) If a complete uniform cost report is not
			 filed by the due date, the hospital shall be charged a penalty of $100.00 per
			 day for each calendar day after the due date.
(4) Hospitals that terminate participation in
			 the Medicaid program must provide a final cost report within 120 days of the
			 date of termination of participation.
Author:
Statutory Authority:
State Plan, Attachment
				  4.19-A; 42 C.F.R. Section 447, Subpart D.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-5 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS 65 OR OVER › Section 560-X-5-.09 - Inspection Of Care

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 Medicaid Quality Assurance Program will periodically perform an inspection of
			 care and services provided to recipients in accordance with 42 C.F.R. Part 456,
			 Subpart I. The review team must consist of psychiatrist or physician with
			 knowledge and experience in the provision of care in mental institutions and
			 other appropriate mental health and social service personnel. This physician
			 may not inspect the care of a recipient for whom he is the attending physician
			 or for whom he has served as the consulting physician. The Medicaid Agency will
			 determine, based on the quality of care and services provided in the facility
			 and the condition of recipients in the facility, at what intervals inspections
			 will be made. However, the review team must inspect the care and services
			 provided to each recipient in the facility at least annually. The inspection
			 must include:
(a) Personal contact with and
			 observations of each recipient; and/or
(b) Review of each recipient's medical
			 record.
In making determination of adequacy of services, the team may
				consider items such as, but not limited to:
(a) The medical, social, and psychiatric
			 evaluations and an assessment of the adequacy and completeness of the plan of
			 care;
(b) The plan of care is
			 followed;
(c) All services ordered
			 are provided and properly documented;
(d) The attending physician reviews of
			 prescribed medication regimens are made at the appropriate times and properly
			 documented;
(e) Tests or
			 observations of each recipient indicated by his medication regimen are made at
			 appropriate times and properly documented;
(f) Professional progress notes are made as
			 required and consistent with the observed condition of the recipient;
(g) The recipient receives adequate services
			 based on observation;
(h) The
			 recipient needs continued inpatient care; and
(i) Alternative care is available and
			 appropriate.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-5 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS 65 OR OVER › Section 560-X-5-.10 - Inpatient Utilization Review

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The determination of the level of care
			 will be made by a licensed nurse of the hospital staff.
(2) Five percent of all admissions and
			 concurrent stay charts will be retrospectively reviewed by the Medicaid Agency
			 or designee on a monthly basis.
(3)
			 For an individual who applies for Medicaid while in the facility, a Psychiatric
			 Admission form must be signed by the attending physician at the time
			 application for Medicaid is made.
(4) The following information shall be
			 included on the Physician Admission Form:
(a)
			 Recipient information:
1. admitting
			 diagnosis;
2. events leading to
			 hospitalization;
3. history of
			 psychiatric treatment;
4. current
			 medications;
5. physician
			 orders;
6. presenting signs and
			 symptoms.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-5 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS 65 OR OVER › Section 560-X-5-.11 - Continued Stay Reviews

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 hospital's utilization review personnel will be responsible for performing
			 continued stay reviews on recipients who require continued inpatient
			 hospitalization.
(2) The initial
			 continued stay review should be performed on the date assigned by Medicaid.
			 Subsequent reviews should be performed at least every 90 days from the initial
			 CSR date assigned, provided the patient is approved for continued stay. Each
			 continued stay review date assigned should be recorded in the patient's
			 record.
(3) If the facility's
			 utilization review personnel determines the patient does not meet the criteria
			 for continued stay, the case should be referred to the facility's psychiatric
			 advisor. If the advisor finds that the continued stay is not needed, the
			 hospital's utilization review procedure for denial of a continued stay should
			 be followed.
(4) If a final
			 decision of denial is made, the hospital must notify the recipient and the
			 attending physician within two days of the adverse determination. Medicaid
			 should be notified in writing within ten (10) days after the denial is
			 made.
(5) The facility's
			 utilization review personnel shall be responsible for phoning Medicaid with a
			 report whenever patients are placed on leave status or return from leave. A
			 brief summary describing the outcome of the therapeutic leave should be
			 addressed at this time for patients returning from any leave status.
Author:
Statutory Authority:
42 C.F.R. Section
				  441.102; Section 456.231 through
				  456.238.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.01 - Physician Program-General

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 The term "physician" shall mean
(a) a doctor
			 of medicine or osteopathy legally authorized to practice medicine and surgery
			 by the state in which the doctor performs such functions;
(b) a doctor of dentistry or of dental or
			 oral surgery who is licensed to practice in the state in which the service is
			 rendered, and legally authorized to perform such function but only with respect
			 to: surgery related to the jaw, the reduction of any fracture related to the
			 jaw or facial bones, or surgery within the oral cavity for removal of lesions
			 or the correction of congenital defects.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.03 - Submission Of Claims By Hospital-Based Physicians

Current through Register Vol. 42, No. 9, June 28, 2024
Hospital-based physicians will be reimbursed under the same
				general system as is used in Medicare. Bills for services rendered will be
				submitted as follows:
(1) All
			 hospital-based physicians, including emergency room physicians, radiologists,
			 and pathologists, shall bill the Medicaid program on a CMS-1500, Health
			 Insurance Claim form or assign their billing rights to the hospital, which
			 shall bill the Medicaid program on a CMS-1500 (Health Insurance Claim) form.
(a) Physician services personally rendered
			 for individual patients will be paid only on a reasonable charge basis (i.e.,
			 claims submitted under an individual provider number on a physician claim
			 form). This includes services provided by a radiologist and/or
			 pathologist.
(b) Reasonable charge
			 services are: a.) personally furnished for a patient by a physician; b.)
			 ordinarily require performance by a physician; and c.) contribute to the
			 diagnosis or treatment of an individual patient.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.04 - Submission Of Claims: Routing Of Claims

Current through Register Vol. 42, No. 9, June 28, 2024
(1) MEDICAID ELIGIBLES.
(a) Claims should be submitted to the fiscal
			 agent in accordance with instructions for these patients who are enrolled for
			 MEDICAID ONLY.
(b) Reimbursement
			 for physicians' services will NOT be made to the patient, sponsor, or nursing
			 facility. The Medicaid program does not provide for reimbursement of this
			 expense to these individuals or facilities.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.05 - Submission Of Claims

Current through Register Vol. 42, No. 9, June 28, 2024
Out of State Claims DO NOT Need Prior Approval. Except for
				those services which require prior approval as stated in Chapters 1 and 6 of
				this Administrative Code (i.e. transplants and select surgeries), medical care
				outside the State of Alabama does not require prior authorization by the
				Alabama Medicaid Agency.
Authors:
Janet B. Young; Debra
				Moore
Statutory Authority:
Title XIX, Social Security
				  Act; 42 C.F.R. §§401, et seq.; State Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.06 - Medicaid Provider Payments

Current through Register Vol. 42, No. 9, June 28, 2024
Payment from Medicaid funds can be made to the actual provider
				of service only. The only exceptions to this rule are payments made within the
				same group, or for substitute physicians.
Authors:
Janet B. Young; Debra
				Moore
Statutory Authority:
Title XIX, Social Security
				  Act; 42 C.F.R. §§401, et seq.; State Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.07 - Enrollment Of Out Of State Providers

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An outofstate physician who wishes to
			 participate in the Alabama Medicaid Program must enroll with the Alabama
			 Medicaid Program and be assigned a provider identification number. To do so,
			 the physician should send a written request to Medicaid's fiscal agent,
			 Provider Enrollment Division. The following information must be included in the
			 enrollment application:
(a) Name;
(b) Address of Place of Business;
(c) Provider Type and specialty;
(d) Social Security Number;
(e) Federal Employer Identification
			 Number;
(f) Medicaid license
			 Number;
(g) Personal Historical
			 Data; and
(h) Original Provider
			 Signature.
Author:
Janet B. Young
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.08 - Consent Statements Required Before Services Are Provided

Current through Register Vol. 42, No. 9, June 28, 2024
Refer to the rules regarding consent and authorization
				contained in paragraphs within this chapter regarding sterilization, and
				abortions, Chapter 14 of this Code, and to Title 22, Chapter 8, Code of Ala.
				1975. Note: Nontherapeutic sterilization performed for the sole purpose of
				rendering a person permanently incapable of reproducing is not available to
				persons under twenty-one (21) years of age under the Medicaid Program.
Author:
Mary Timmerman, Associate Director;
				Medical Services Program
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 C.F.R.
				  §§441.257, 401, et seq.; State
				  Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.09 - Consent Forms Required Before Payments Can Be Made

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Abortions: A claim seeking payment for an
			 abortion must be accompanied by one or more (depending on the circumstance) of
			 the forms required by federal law and a copy of the medical records. Payment is
			 available for abortions as provided under federal law.
(a) In the event the abortion does not meet
			 the requirements of federal law, and the recipient elects to have the abortion,
			 the provider may bill the recipient for the abortion.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.10 - Physician's Role In Certification And Recertification

Current through Register Vol. 42, No. 9, June 28, 2024
(1) For information about hospital
			 certification and recertification see Rule
			 560-X-7-.16.
(2) In a skilled or intermediate nursing care
			 facility, in the hospital and for the Home Health Care Program, Medicaid
			 patients must be recertified by a physician at least every sixty (60) days. The
			 certification form will be made a permanent part of the patient's record.
Author:
James F. Adams
Statutory Authority:
Title XIX, Social Security
				  Act; 42 C.F.R. §§401, et seq.; State Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.11 - Physician's Role In Extension Of Hospital Days

Current through Register Vol. 42, No. 9, June 28, 2024
With the exception of Medicaid recipients eligible for
				treatment under the EPSDT (MediKids) program, additional hospital days are not
				covered. Refer to Chapter 7, Hospital Program and Chapter 11, EPSDT, for
				specifics.
Author:
Statutory Authority:
Title XIX, Social Security
				  Act; 42 C.F.R. §§401, et seq.; State Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.12 - Covered Services: General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In general, physician services are
			 covered by Medicaid if the services are:
(a)
			 Considered medically necessary by the attending physician. However, when the
			 persons designated responsible for utilization review have issued a denial for
			 inpatient days, no ancillary charge or professional charges will be reimbursed
			 during the denied period.
(b)
			 Designated by procedure codes in Physicians' Current Procedural Terminology
			 (CPT), or designated by special procedure codes created by Medicaid for its own
			 use.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.14 - Limitations On Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Within each calendar year each recipient is limited to no more than a total of
			 14 physician office visits in offices, hospital outpatient settings, nursing
			 homes, or Federally Qualified Health Centers. Visits counted under this quota
			 will include, but not be limited to, visits for: prenatal care, postnatal care,
			 family planning, second opinions, consultations, referrals, psychotherapy
			 (individual, family, or group), for ESRD services not covered by the monthly
			 capitation payment, and care by ophthalmologists for eye disease. Physician
			 visits provided in a hospital outpatient setting that have been certified as an
			 emergency do not count against the annual office visit limit.
(a) If a patient receives ancillary services
			 in a doctor's office, by the physician or under his/her direct supervision, and
			 the doctor submits a claim only for the ancillary services but not for the
			 office visit, then the services provided will not be counted as a
			 visit.
(b) For further information
			 regarding outpatient maintenance dialysis and ESRD, refer to
			 560-X-6-.19 and Chapter
			 24.
(c) New patient office visit
			 codes shall not be paid to the same physician or the same physician group
			 practice for a recipient more than once in a three-year period.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.16 - Billing Of Medicaid Recipients By Providers

Current through Register Vol. 42, No. 9, June 28, 2024
A provider may bill Medicaid recipients for the copay amount,
				for Medicaid noncovered services and for services provided to a recipient who
				has exhausted his/her yearly limitations. Conditional collections to be
				refunded post payment by Medicaid and partial charges for balance of Medicaid
				allowed reimbursement are not permissible. Billing recipient for services not
				paid by Medicaid due to provider correctable errors on claims submission or
				untimely filing is not permissible.
Author:
Janet B. Young
Statutory Authority:
Title XIX, Social Security
				  Act,
				  42 C.F.R.
				  §§447.15, et seq.; State
				  Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.17 - Copayment (Cost-sharing)

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medicaid recipients are required to pay, and physician providers are required
			 to collect, the designated copayment amount on each physician visit. The
			 copayment amount does not apply to services provided for the following:
(a) Pregnancy
(b) Nursing home residents
(c) Inpatient hospital visits
(d) Recipients under 18 years of
			 age
(e) Emergencies
(f) Surgery fees
(g) Physical therapy
(h) Family planning
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.18 - Critical Care

Current through Register Vol. 42, No. 9, June 28, 2024
(1) When caring
			 for a critically ill patient in which the constant attention of the physician
			 is required, the appropriate critical care procedure code must be billed. Refer
			 to the CPT and the Alabama Medicaid Provider Manual for additional guidance and
			 clarification.
(2) The actual time
			 period, per day, spent in attendance at the patient's bedside, or performing
			 duties specifically related to that patient, irrespective of breaks in
			 attendance, must be documented in the patient's medical record.
(3) Only the following individual procedures
			 related to critical care may be billed:
(a)
			 Procedure code 99360 (stand by) and either procedure code 99221, 99222, or
			 99223 (initial hospital care) may be billed once with each hospital
			 stay.
(b) An EPSDT screening may be
			 billed in lieu of the initial hospital care (Procedure code 99221, 99222, or
			 99223).
(c) Procedure code 99082
			 (transportation/escort of patient) may be billed only by the attending
			 physician. Residents or nurses who escort a patient may not bill either
			 service.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.19 - Physician Services For End Stage Renal Disease. (ESRD)

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All physician services rendered to each
			 outpatient maintenance dialysis patient provided during a full month on an
			 ongoing basis without interruption of the treatment regime (uninterruptedly)
			 shall be billed on a monthly capitation basis. The monthly capitation payment
			 is limited to once per month, per recipient, per provider.
(2) Physician services rendered to each
			 outpatient maintenance dialysis patient not performed consecutively
			 (interruptedly) during a full month, i.e., preceding and/or following the
			 period of hospitalization, are allowed. Please refer to the physician's chapter
			 of the provider Manual for further details.
(3) Services not covered by the monthly
			 capitation payment (MCP) and which are reimbursed in accordance with usual and
			 customary charge rules are limited to:
(a)
			 Declotting of shunts.
(b) Covered
			 physician services furnished to hospital inpatients by a physician who elects
			 not to receive the MCP for these services.
(c) Nonrenal related physician services.
			 These services may be furnished either by the physician providing renal care or
			 by another physician. They may not be incidental to services furnished during a
			 dialysis session or office visit necessitated by the renal condition.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.01 - Hospital Program - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Title XIX (Medicaid) Plan for Alabama
			 provides for inpatient care for adults and children in accordance with
			 42
			 C.F.R. §440.10 and for preventive,
			 diagnostic, therapeutic, rehabilitative, or palliative outpatient services in
			 accordance with
			 42
			 C.F.R. §440.20. Inpatient hospital days
			 will be reimbursed as described in Chapter 23, Hospital
			 Reimbursement.
Author:
Solomon Williams, Associate Director,
				  Institutional Services
Statutory Authority:
State Plan; Attachment
				  3.1-A, pp 1 & 1.1;
				  42
				  C.F.R. §§440.10,
				  440.20,
				  441.57;
				  Omnibus Budget Reconciliation Act of 1985 (COBRA, Public Law 99-272); Medicare
				  Catastrophic Coverage Act of 1988 ( Public Law 100-360); Omnibus Budget
				  Reconciliation Act of 1990 (Public
				  Law 101-508).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.02 - Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Eligibility. In
			 order to participate in the Title XIX Medicaid program and to receive Medicaid
			 payment for inpatient and outpatient hospital services, a hospital provider
			 must meet the following requirements:
(a) Be
			 certified for participation in the Title XVIII Medicare and Title XIX Medicaid
			 programs as a short term or children's hospital. Hospital types are identified
			 on the Hospital Request for Certification in the Medicare/Medicaid Program
			 (HCFA-1514) or its successor.
(b)
			 Be licensed as a hospital by the State of Alabama in accordance with current
			 rules contained in the Alabama Administrative Code Chapter 420-5-7.
(c) Be in compliance with Title VI of the
			 Civil Rights Act of 1964 and with Section 504 of the Rehabilitation Act of
			 1973.
(d) Submit a letter
			 requesting enrollment.
(e) Submit a
			 budget of cost for medical inpatient services for its initial cost reporting
			 period, if a new facility.
(f)
			 Execute the Alabama Medicaid Provider Agreement for participation in the
			 Medicaid program.
(g) Submit a
			 written description of an acceptable utilization review plan currently in
			 effect.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.03 - Inpatient Benefits

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An
			 inpatient is a person who has been admitted to a hospital for bed occupancy for
			 purposes of receiving inpatient hospital services. A person is considered an
			 inpatient with the expectation that he will remain at least overnight and
			 occupy a bed (even though it later develops he can be discharged or is
			 transferred to another hospital and does not use a bed overnight.)
(2) The number of days of care charged to a
			 recipient for inpatient hospital services is always in units of full days. A
			 day begins at midnight and ends 24 hours later. The midnight-to-midnight method
			 is to be used in reporting days of care for the recipients, even if the
			 hospital uses a different definition of day for statistical or other
			 purposes.
(3) Medicaid covers the
			 day of admission, but not the day of discharge. If admission and discharge
			 occur on the same day, the day is considered a day of admission and counts as
			 one inpatient day.
(4) Newborn
			 well-baby nursery charges will be covered by an eligible mother's claim for up
			 to ten days nursery care for each baby if the mother is in the hospital and is
			 otherwise entitled to such coverage.
(a) For
			 well-baby nursery charges, revenue codes 170 and 171 are reflected on the
			 mother's claim in conjunction with her inpatient stay for the delivery. The
			 hospital per diem rate includes charges for the mother and newborn.
(b) Newborn "well-baby" care is not
			 separately billable. Nursery charges for "boarder babies", infants with no
			 identified problems or condition whose mothers have been discharged, were never
			 admitted to the hospital, or are not otherwise eligible for Medicaid are not
			 separately billable.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.04 - Bed And Board In Semi-Private Accommodations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Medicaid will pay for semiprivate
			 accommodations (two, three, or fourbed accommodations). When accommodations
			 other than semiprivate are furnished, the following rules will govern:
(a) Private rooms medically necessary Payment
			 may be made for private room or other accommodations more expensive than
			 semiprivate only when such accommodations are medically necessary. Private
			 rooms will be considered medically necessary when the patient's condition
			 requires him to be isolated for his own health or that of others. The term
			 isolation may apply when treating a number of physical or mental conditions.
			 These include communicable diseases which require isolations of the patient for
			 certain periods. Privacy may also be necessary for patients whose symptoms or
			 treatments are likely to alarm or disturb others in the same room. Payment will
			 be made for the use of intensive care facilities where medically necessary. In
			 order for the private room to be covered by Medicaid, the following conditions
			 must be met:
(1) The physician must certify
			 at the time of admission or within 48 hours of the onset of the need for a
			 private room, the specific medical condition requiring a private
			 room.
(2) Such certification must
			 appear in the hospital records as a written order by the physician.
(3) At the time the physician certifies the
			 need for continued hospitalization, the private room must also be recertified
			 as being medically necessary. Medicaid will not cover a private room on the
			 basis of a retroactive statement of medical necessity by the physician. At the
			 time the medical Medicaid Chapter 560-X-7 necessity for a private room ceases,
			 the patient should be placed in the type accommodation covered by
			 Medicaid.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.05 - Nursing And Other Services

Current through Register Vol. 42, No. 9, June 28, 2024
Nursing and other related services, use of hospital facilities,
				and the medical social services ordinarily furnished by the hospital for the
				care and treatment of inpatients are covered.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401, et seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.06 - Drugs And Biologicals

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Drugs and biologicals for use in the hospital which are ordinarily furnished by
			 the hospital for the care and treatment of inpatients are covered.
(2) Takehome drugs and medical
(3) A patient may, on discharge from the
			 hospital, take home remaining amounts of drugs which have been
(4) Medically necessary takehome drugs should
			 be provided by written prescription either through the hospital pharmacy or any
			 other Medicaid approved pharmacy.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401, et seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.07 - Supplies, Appliances, And Equipment

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Supplies, appliances, and equipment
			 furnished by the hospital solely for the care and treatment of a recipient
			 during an inpatient stay in the hospital are covered as part of the hospital
			 per diem payment.
(2) Supplies,
			 appliances, and equipment furnished to an inpatient for use only outside the
			 hospital are not generally covered as inpatient hospital services. A temporary
			 or disposable item, however, which is medically necessary to permit or
			 facilitate the patient's departure from the hospital and is required until the
			 patient can obtain a continuing supply is covered as part of the hospital per
			 diem payment.
Author:
Lynn Sharp, Associate Director, Policy
				Development Unit
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401, et seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.08 - Hemodialysis

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Hemodialysis
			 for chronic renal cases is provided under the Medicaid Program when the patient
			 is not authorized this care under Medicare.
(2) Refer to Chapter One, Rule No.
			 560-X-1-.27, of the
			 Administrative Code for kidney transplant coverage.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401, et seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.09 - Blood

Current through Register Vol. 42, No. 9, June 28, 2024
Charges for whole blood or equivalent quantities of packed red
				cells are not allowable since Red Cross provides blood to hospitals. However,
				blood processing and administration is a covered service.
Author:
Vicki W. Huff
Statutory Authority:
State Plan, Attachment
				  3.1A; Title XIX, Social Security Act;
				  42 C.F.R.
				  §409.87.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.10 - Sterilization And Hysterectomy

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Surgical procedures for male and female recipients as method of birth control
			 are covered services under the conditions set forth in the chapter pertaining
			 to Family Planning.
(2) Any Alabama
			 Medicaid hospital claim that relates to any sterilization or hysterectomy must
			 have documentation attached to it showing or consisting of a consent form or an
			 acknowledgment of receipt of hysterectomy information. These attachments must
			 meet the criteria set forth under the sterilization and hysterectomy
			 regulations. See the Physicians' Chapter and the Family Planning Chapter for
			 further details.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.11 - Abortions

Current through Register Vol. 42, No. 9, June 28, 2024
Payment for abortions under the Medicaid Program is subject to
				the conditions in the chapter pertaining to Physicians. See the Physicians'
				Chapter for further details.
Author:
Charles A. Reasner
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401, et seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.12 - Physical Therapy

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Physical
			 therapy is a covered service based on medical necessity. Physical therapy
			 services that do not require the professional skills of a qualified physical
			 therapist to perform or supervise are not considered medically necessary.
			 Physical therapy is covered:
(a) in a hospital
			 outpatient setting, and
(b) for
			 acute conditions.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.13 - Adverse Events, Hospital-Acquired Conditions, And Present On Admission Indicators

Current through Register Vol. 42, No. 9, June 28, 2024
(1) This
			 rule applies to inpatient hospital admissions beginning dates of admission on
			 or after July 1, 2010.
(2) Adverse
			 Events are the events that must be reported to Medicaid by the hospital. To be
			 reportable, these events must meet the following criteria:
(a) The event must be reasonably preventable
			 as determined by a root cause analysis or some other means.
(b) The event must be within the control of
			 the hospital.
(c) The event must be
			 clearly and unambiguously the result of a preventable mistake made and hospital
			 procedures not followed, and not an event that could otherwise occur.
(d) The error or event must result in
			 significant harm. The events for consideration should be limited to those that
			 yield a serious adverse result. Serious adverse result is defined as one that
			 results in death, a serious disability or a substantial increase in the
			 duration and/or complexity of care that is well beyond the norm for treatment
			 of the presenting condition. A serious disability is defined as a major loss of
			 function that endures for more than 30 days, is not present at the time
			 services were sought and is not related to the presenting condition.
(e) Any process for identifying non-payable
			 events must actively incorporate some element of case-by-case review and
			 determination. While the source and cause of some adverse events may be clear,
			 most would require further investigation and an internal root cause analysis to
			 determine the cause of the serious preventable event and to assign ultimate
			 accountability.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.14 - Dental Services

Current through Register Vol. 42, No. 9, June 28, 2024
Items and services in connection with the care, treatment,
				filling, removal or replacement of teeth, or structures directly Early and
				Periodic Screening, Diagnosis, and Treatment program. See Chapter 15, Dental
				Services for details.
Authors:
Ruth H. Chambliss, Charles A.
				Reasner.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§441.50,
				  441.56.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.16 - Utilization Review For Inpatient Hospital Admissions And Concurrent Stays

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Medicaid will
			 utilize Alabama Medicaid Adult and Pediatric Inpatient Care Criteria (SI/IS)
			 for utilization review, billing and reimbursement purposes.
(a) It is the hospital's responsibility to
			 utilize its own physician advisor.
(b) The attending physician and/or resident
			 may change an order up to 30 days after discharge, as long as the patient met
			 criteria for inpatient or observation services.
(c) Refer to Chapter 3 of this Administrative
			 Code for the fair hearings/appeals process.