reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.17 - Outpatient Hospital Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) "Outpatient hospital services" means
			 preventive, diagnostic, therapeutic, rehabilitative, or palliative services
			 provided to an outpatient by or under the direction of a physician/dentist at a
			 licensed hospital.
(2) Medical
			 services provided in the outpatient department must be identified and the
			 specific treatment documented in the medical record.
(3) Outpatient surgical services are those
			 covered procedures commonly performed on an inpatient basis that may be safely
			 performed on an outpatient basis. Only those surgeries included on the Medicaid
			 outpatient hospital fee schedule will be covered on an outpatient basis.
			 Surgeries included on the Medicaid outpatient surgical list are reimbursable
			 when provided on an inpatient basis if utilization review criteria are met.
(a) Surgical procedures that are not listed
			 on Medicaid's outpatient fee schedule may be sent to the Institutional Services
			 Unit to be considered for coverage in the outpatient setting if medically
			 necessary and the procedure is approved by the Medical Director.
(b) Refer to the Outpatient Hospital Fee
			 Schedule on the Medicaid website for a list of covered surgical
			 codes.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.18 - Patient Signature

Current through Register Vol. 42, No. 9, June 28, 2024
(1) While
			 a recipient signature is not required on individual claim forms, all providers
			 must obtain a signature to be kept on file, (e.g., release forms or sign in
			 sheets), as verification that the recipient was present on the date of service
			 for which the provider seeks payment. Exceptions to the recipient signature
			 requirement are listed below.
(a) When there
			 is no personal recipient/provider contact, such as laboratory or radiology
			 services.
(b) Illiterate recipients
			 may make their mark, for example, "X", witnessed by someone with their dated
			 signature after the phrase "witnessed by."
(c) If the patient cannot sign due to
			 physical or mental impairment or because of age, an authorized person may sign
			 for the patient indicating his/her relationship to the patient.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.19 - Diagnosis And Procedure Codes. (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
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-.20 - Hospital Based Physicians, Submission Of Claims

Current through Register Vol. 42, No. 9, June 28, 2024
Reference Chapter 6 Physicians and Chapter 23 Hospital
				Reimbursement Program for details.
Authors:
Ruth H. Chambliss, Charles A.
				Reasner
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§405.401, 405.522, 405.523.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.21 - Outpatient And Inpatient Tests

Current through Register Vol. 42, No. 9, June 28, 2024
Based on PL 9735, the "Omnibus Budget Reconciliation Act of
				1981," Section 2164(a) and
				42 CFR Part
				441.12, effective October 1, 1981, Medicaid
				will pay only for laboratory tests or xrays or any other type of test provided
				in inpatient or outpatient hospital facilities which have been ordered by the
				attending physician or other staff physician. There will be no payment made for
				tests under "standing orders" or "routine orders."
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-.22 - Claim Filing Guidelines

Current through Register Vol. 42, No. 9, June 28, 2024
(1) For claim filing guidelines, refer to
			 Chapter 5, (Filing Claims) of the Provider Manual or Chapter 19 (Hospital) of
			 the Provider Manual.
(2) Claims
			 containing fragmentation of services may be recouped through post-payment
			 review.
Author:
Lynn Sharp, Associate Director, Policy
				  Development Unit
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42
				  C.F.R. §§
											447.45,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.23 - Third Party Payment Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
For guidelines on submitting claims to Medicaid when a third
				party is involved, refer to the Hospital Billing Manual.
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-.24 - Sending Bills And Statements To Medicaid Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Providers should not send recipients
			 bills or statements for covered services once that recipient has been accepted
			 as a Medicaid patient.
(2)
			 Providers may send a notice to the recipient stating their claim is still
			 outstanding if the notice indicates in bold letters: "THIS IS NOT A
			 BILL."
(3) Providers are
			 responsible for followup with the fiscal agent or Medicaid on any billing
			 problems or unpaid claims.
(4) The
			 Recipients are not responsible for the difference between charges billed and
			 the amount paid by Medicaid for covered charges services.
(5) Providers agree to accept the amount paid
			 by Medicaid as payment in full.
(6)
			 Recipients may be billed only for the allowable copayment amount, for services
			 not covered by Medicaid, or when benefits have been exhausted.
(7) Providers may not deny services to any
			 eligible recipient due to the recipient's inability to pay the allowable
			 copayment amount.
Author:
Lynn Sharp, Associate Director, Policy
				Development Unit
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§447.15,
				  447.50,
				  447.55.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.25 - Prior Authorization

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Out-of-State Referrals -- Prior authorization will be required for organ
			 transplants and select surgical procedures. (Refer to Rule No.
			 560-X-1-.27 and Rule No.
			 560-X-6-.13
			 respectively).
(2) Dental
			 Hospitalization -- See Chapter 15, Dental Services, for details.
Previously Rule No. 670-X-7-.26.
Amended
effective October 12, 1988.
Emergency rule
effective January 1,
				  1989.
Amended
effective March 14, 1989; April 17, 1990; January
				  15, 1991; October 12, 1991; October 13, 1992.
Amended:
Filed March
				  7, 1997; effective April 11, 1997.
Amended:
Filed November 10,
				  2010; effective December 15, 2010.
Amended:
Filed June 11, 2015;
				  effective July 16, 2015.
Author:
Solomon Williams, Associate Director,
				  Institutional Services
Statutory Authority:
State Plan, Attachment
				  3.1-A; Title XIX, Social Security Act; 42 C.F.R. §431.25 .
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.26 - Medicare/Medicaid Eligible Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Inpatient Refer to Rule
			 560-X-1-.14 for
			 details.
(2) Outpatient Part B.
			 Payment for outpatient crossover claims shall be based on the lesser of the
			 coinsurance and/or deductible amount or the Medicare allowed amount times the
			 outpatient percentage rate minus the Medicare paid amount.
Authors:
Cecil Martin, James V. Harris, Ruth H.
				Chambliss, Vicki W. Huff
Statutory Authority:
State Plan, Attachment
				  3.1A, 3.2A;
				  42 C.F.R.
				  §§409.60, .80, .83; Medicare
				  Catastrophic Coverage Act of 1988 ( Public Law 100360).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.27 - Split Billing (Inpatient Claims) (Repealed)

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Jerri Jackson, Associate Director,
				  Institutional Services
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-.28 - Copayment (Cost Sharing)

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 The Medicaid recipient shall pay the allowable copayment amount for each
			 inpatient admission under the Medicaid program, except for the designated
			 exemptions. The copayment amount does not apply to services provided for the
			 following:
(a) Recipient under 18 years of
			 age
(b) Pregnancy
(c) Renal dialysis
(d) Emergencies
(e) Family planning
(f) Chemotherapy
(g) Radiation therapy
(h) Nursing home residents
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.29 - Payment Of Outpatient Hospital Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Payment for all outpatient hospital
			 services will be from approved rates as established by Medicaid.
(2) Publicly owned hospitals and hospitals
			 which predominantly treat children under the age of 18 years may be paid at an
			 enhanced payment. These payments shall not exceed combined payments for
			 providing comparable services under comparable circumstances under Medicare.
Author:
Ruth H. Chambliss
Statutory Authority:
State Plan, Attachment
				  4.18A;
				  42 C.F.R.
				  §§447.15, .50, .55.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-7 - HOSPITALS › Section 560-X-7-.30 - Post-Hospital Extended Care Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Inpatient hospital services rendered at
			 an inappropriate level of care (lower than acute) are considered posthospital
			 extended care services. The patient must have received a minimum of three
			 consecutive days of acute care services in the hospital requesting
			 Post-Hospital Extended Care (PEC) reimbursement. Infrafacility transfers will
			 not be authorized for reimbursement as PEC services. These services include
			 care ordinarily provided by a nursing facility. (Refer to Chapter 10.) Such
			 medically necessary services include, but are not limited to:
(a) Nursing care provided by or under the
			 supervision of a registered nurse on a 24hour basis;
(b) Bed and board in a semiprivate room.
			 Private accommodations may be utilized if the patient's condition requires that
			 he/she be isolated, the facility has no ward or semiprivate rooms, or all ward
			 or semiprivate rooms were full at the time of admission and remain so during
			 the recipient's stay;
(c) Medically
			 necessary overthecounter (nonlegend) drug products ordered by physician.
			 Generic brands are required unless brand name is specified in writing by the
			 attending physician;
(d) Personal
			 services; and
(e) Nursing and
			 treatment These include, but are not limited to, needles, syringes, catheters,
			 catheter trays, drainage bags, indwelling catheters, enema bags, normal
			 dressing, special dressings (such as ABD pads and pressure dressings),
			 intravenous administration sets, and normal intravenous fluids (such as
			 glucose, D5W, D10W, and normal saline);
(f) Services ordinarily furnished to an
			 inpatient of a hospital.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-8 - INDEPENDENT RURAL HEALTH CLINIC SERVICES › Section 560-X-8-.01 - Independent Rural Health Clinic Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Independent Rural Health Clinics must be
			 Medicare certified and contracted with the Alabama Medicaid Program, and be in
			 compliance with Federal, State and Local Laws.
(2) Services covered under the Independent
			 Rural Health Clinic Program are any medical service typically furnished by a
			 physician in an office or in a physician home visit. Limits are the same as for
			 the Physician Program.
(3)
			 Independent Rural Health Clinic services are reimbursable if:
(a) performed by a physician,
(b) performed by a nurse practitioner,
			 physician assistant, certified nurse midwife, or clinical social worker as an
			 incident to a physician's service,
(c) a physician, nurse practitioner,
			 physician assistant, or certified nurse midwife is available to furnish patient
			 care at all times the clinic operates, and
(d) a nurse practitioner, physician
			 assistant, or certified nurse midwife is available to furnish patient care at
			 least 50 percent of the time the clinic operates.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-8 - INDEPENDENT RURAL HEALTH CLINIC SERVICES › Section 560-X-8-.02 - Other Ambulatory Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The following services are covered as
			 other ambulatory services furnished in an Independent Rural Health Clinic and
			 are not billed as Rural Health Clinic services:
(a) Dental Services,
(b) Eyeglasses;
(c) Hearing aids;
(d) Prescribed devices;
(e) Prosthetic devices and
(f) Durable medical equipment;
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-8 - INDEPENDENT RURAL HEALTH CLINIC SERVICES › Section 560-X-8-.03 - Reimbursement

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Independent
			 Rural Health Clinics (IRHCs) will be reimbursed under a Prospective Payment
			 System (PPS) as described in Chapter 56 of the Administrative Code.
(2) Encounters are all-inclusive and all
			 services provided for the visit are included in the reimbursement rate. The
			 only exceptions are claims for laboratory services and for the technical
			 component of EKG's and radiology services.
Author:
Calvin Binion, Associate Director, State
				  Agency, Vision, & Clinic Services
Statutory Authority:
42 C.F.R., §§
											447.371, et seq. ; State Plan for Medical
				  Assistance, Attachment 4.19-B, page 1.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-8 - INDEPENDENT RURAL HEALTH CLINIC SERVICES › Section 560-X-8-.04 - Change Of Ownership

Current through Register Vol. 42, No. 9, June 28, 2024
Medicaid must be notified within thirty (30) days of the date
				of Independent Rural Health Clinic ownership change. The existing contract will
				be automatically assigned to the new owner, and the new owner shall then be
				required to execute a new contract with Medicaid as soon as possible after the
				change of ownership but in no event later than thirty (30) days after the new
				owner receives notification of Medicare certification. If the new owner fails
				to execute a new contract with Medicaid within this time period, then this
				contract shall terminate.
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-8 - INDEPENDENT RURAL HEALTH CLINIC SERVICES › Section 560-X-8-.05 - Medicare Deductible And Coinsurance

Current through Register Vol. 42, No. 9, June 28, 2024
Deductible and/or Co-insurance will be reimbursed up to the
				full amount of the Medicaid encounter rate.
Author:
Carol Akin, Associate Director,
				Clinic/Ancillary Services
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-8 - INDEPENDENT RURAL HEALTH CLINIC SERVICES › Section 560-X-8-.06 - Copayment (Cost-Sharing)

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medicaid and Medicare/Medicaid related recipients are required to pay and
			 independent rural health clinics are required to collect the established
			 copayment amount for each clinic encounter.
(2) The cost-sharing requirement does not
			 apply to services provided for the following:
(a) Recipients under 18 years of
			 age;
(b) Emergencies;
(c) Pregnancy;
(d) Family Planning;
(e) Nursing home residents;
(f) American Indians
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-8 - INDEPENDENT RURAL HEALTH CLINIC SERVICES › Section 560-X-8-.07 - Billing Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 provider agrees to accept as payment in full the amount paid by the State, plus
			 any copayment amount required to be paid by the recipients, for covered items
			 and further agrees to make no additional charge or charges for covered items to
			 the recipient.
(2) A provider may
			 bill the recipient for the copayment amount and for noncovered Medicaid
			 services.
(3) A provider may not
			 deny services to any eligible individual on account of the individual's
			 inability to pay the copayment amount.
Author:
Ronald B. Ressler
Statutory Authority:
42 C.F.R.
				  §447.15; State Plan, Attachment
				  4.18-A.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-9 - INDEPENDENT LABORATORY SERVICES › Section 560-X-9-.01 - Independent Laboratory Services-General

Current through Register Vol. 42, No. 9, June 28, 2024
The Alabama Medicaid Agency will pay for services provided by
				independent laboratories that are enrolled by contract under the following
				conditions:
(1) The services must be
			 medically necessary.
(2) The
			 patient must be eligible for Medicaid at the time the services are rendered.
Authors:
James F. Adams, Sheila G. Dunbar, Debra
				Moore
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §440.30.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-9 - INDEPENDENT LABORATORY SERVICES › Section 560-X-9-.02 - Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
Laboratory Services are professional and technical laboratory
				services -
(a) ordered and provided by
			 or under the direction of a physician or other licensed practitioner of the
			 healing arts within the scope of his practice as defined by state
			 law;
(b) ordered by a physician but
			 provided by a referral laboratory;
(c) provided in an office or similar facility
			 other than a hospital outpatient department or clinic; and
(d) provided by a laboratory that meets the
			 requirements for participation in Medicare.
(1) Laboratory services are restricted to
			 those that are described by procedures in the CPT manual (80000 series) or one
			 of the locally assigned HCPCS codes used only by Medicaid to supplement the
			 listing in the CPT manual.
(2)
			 Providers will be paid only for covered services which they are certified to
			 perform and which they actually perform.
(3) Physicians who send specimens to
			 independent laboratories for analysis, and laboratories that provide specimen
			 collection services for referral to other laboratories, may bill for a
			 collection fee. This fee shall not be paid to any provider that has not
			 actually collected the specimen from the patient.
(4) Routine venipuncture for collection of
			 laboratory specimens may be billed only when sending blood specimens to another
			 site for analysis. The collection fee may not be billed if the lab work is done
			 at the same site where the specimen was drawn, or in a lab owned, operated, or
			 financially associated with the site in which the specimen was drawn.
Author:
Lynn Sharp, Associate Director, Policy
				Development Unit
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-9 - INDEPENDENT LABORATORY SERVICES › Section 560-X-9-.03 - Participation Requirements

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Independent laboratories must meet the following requirements for participation
			 in the Alabama Medicaid program:
(a) Be
			 certified for participation with Medicare.
(b) Have a valid CLIA certification (i.e.,
			 clinical labs).
(c) Have a
			 Physician's supervisory Certification and utilize certified technicians for
			 ultrasounds, Doppler services, and non-invasive peripheral vascular studies
			 (i.e., physiological labs).
(d)
			 Must be independent of any hospital, clinic, or physician's office.
(e) Be licensed in the state where located,
			 when it is required by that state.
(f) Submit to routine audits by
			 Medicaid.
(g) Complete an
			 application with all required attachments.
(h) Sign a provider agreement.
(i) Sign a Direct Deposit Authorization.
Sign a Civil Rights Statement of Compliance.
(k) Effective date of enrollment will be the
			 date of issuance of license. If license is not required in the state of
			 residence, the effective date of enrollment will be the date of CLIA
			 certification. However, providers who request enrollment more than 120 days
			 after the above application date will be enrolled on the first day of the month
			 the request for enrollment is received.
Author:
Ginger Collum, Program Manager,
				Clinic/Ancillary Services
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-9 - INDEPENDENT LABORATORY SERVICES › Section 560-X-9-.04 - Reserved

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Debra Moore
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §440.30; §493.2.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-9 - INDEPENDENT LABORATORY SERVICES › Section 560-X-9-.05 - Reserved

Current through Register Vol. 42, No. 9, June 28, 2024
Author:
Debra Moore
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §440.30.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-9 - INDEPENDENT LABORATORY SERVICES › Section 560-X-9-.06 - Claims Filing Guidelines

Current through Register Vol. 42, No. 9, June 28, 2024
(1) For time limits on claims submission
			 refer to the Medicaid Provider Manual, Independent Laboratory
			 chapter.
(2) Claims for lab
			 services must contain a valid diagnosis code.
(3) Claims submitted must contain the
			 provider number of the lab that actually performed the services. Claims must
			 not be submitted using any other provider's number, such as the provider number
			 of the referring physician or hospital.
(4) All organ and disease oriented panels
			 must include the tests listed with no substitutions. If only part of the tests
			 included in a defined panel are performed, the panel code should not be
			 reported. If additional tests to those indicated in a panel are performed,
			 those tests should be reported separately in addition to the panel code. If two
			 panels overlap, the physician or laboratory will be required to unbundle one of
			 the panels and bill only for the tests that are not duplicative.
Author:
Lynn Sharp, Associate Director, Policy
				Development Unit
Statutory Authority:
State Plan, Title XIX
				  Social Security Act; 442 C.F.R. §§405.401 et seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-9 - INDEPENDENT LABORATORY SERVICES › Section 560-X-9-.07 - Reserved

Current through Register Vol. 42, No. 9, June 28, 2024
Authors:
Sheila G. Dunbar, Debra
				Moore
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§405.401,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-9 - INDEPENDENT LABORATORY SERVICES › Section 560-X-9-.08 - Third Party Payment Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
For guidelines on submitting claims to Medicaid when a third
				party is involved, refer to the Medicaid Provider Manual, Independent
				Laboratory chapter.
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-9 - INDEPENDENT LABORATORY SERVICES › Section 560-X-9-.09 - Sending Bills And Statements To Medicaid Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Providers should not send recipients
			 bills or statements for covered services once the recipient has been accepted
			 as a Medicaid patient.
(2)
			 Providers may send a notice to the recipient stating their claim is still
			 outstanding if the notice indicates in bold letters, "THIS IS NOT A
			 BILL".
(3) Providers are
			 responsible for follow-up with the fiscal agent or Medicaid on any billing
			 problems or unpaid claims.
(4)
			 Providers agree to accept the amount paid by Medicaid as payment in
			 full.
(5) Recipients are not
			 responsible for the difference between charges billed and the amount paid by
			 Medicaid for covered services.
(6)
			 Recipients may be billed only for the allowable copayment amount, for services
			 not covered by Medicaid, or when benefits have been exhausted.
(7) Providers may not deny services to any
			 eligible recipient due to the recipient's inability to pay the allowable
			 copayment amount.
Author:
Medicaid Agency
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§447.50,
				  447.55.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-9 - INDEPENDENT LABORATORY SERVICES › Section 560-X-9-.10 - Reserved

Current through Register Vol. 42, No. 9, June 28, 2024
Statutory Authority:
State Plan, Section 3.1;
				  Title XIX Social Security Act;
				  42
				  C.F.R. §440.50; Deficit Reduction Act of
				  1984.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-9 - INDEPENDENT LABORATORY SERVICES › Section 560-X-9-.11 - Reserved

Current through Register Vol. 42, No. 9, June 28, 2024
Previous rule "Claims Processing" effective October 1, 1982.
Emergency repeal
effective October 15, 1990.
Permanent
				  repeal
effective January 15,
				  1991.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-9 - INDEPENDENT LABORATORY SERVICES › Section 560-X-9-.12 - Non-Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medicaid will not pay packing and handling charges for referred laboratory
			 services. Payment for referred tests will be made to the referred laboratory
			 only at the normal rate. This policy shall be monitored through postpayment
			 review by Medicaid.
(2) Medicaid
			 will not pay for lab services provided to Medicare/Medicaid recipients if the
			 services have been determined to be noncovered by Medicare.
Authors:
Charles A. Reasner, Debra Moore; Sharon
				Bean.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§440.30,
				  440.50;
				  Deficit Reduction Act of 1984.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.01 - Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Nursing
			 Facility - An institution which is primarily engaged in providing nursing care
			 and related services for residents who require medical or nursing care,
			 rehabilitation services for the rehabilitation of injured, disabled or sick
			 persons, or on a regular basis health related care and services to individuals
			 who because of their mental or physical condition require care and services
			 which may be made available to them only through institutional facilities. A
			 facility may not include any institution that is for the care and treatment of
			 mental disease except for services furnished to individuals age 65 and
			 over.
(2) Intermediate Care
			 Facility for the Individuals with Intellectual Disabilities (ICF/IID) - An
			 institution that is primarily for the diagnosis, treatment or rehabilitation of
			 the intellectually disabled or persons with related conditions and provides in
			 a protected residential setting, ongoing evaluations, planning, 24 hour
			 supervision, coordination and integration of health or rehabilitative services
			 to help each individual function at their greatest ability.
(3) Institution for Mental Disease (IMD) -
(a) An institution that is licensed as a
			 mental institution; or
(b) More
			 than fifty percent (50%) of the patients are receiving care because of
			 disability in functioning resulting from a mental disease. Mental diseases are
			 those listed under the heading of Mental Disease in the diagnostic and
			 Statistical Manual of Mental Disorders, Current Edition, International
			 Classification of Diseases, adopted for use in the United States (ICD 9) or its
			 successors, except for intellectual disability.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.02 - Long Term Care Program - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Medical Assistance (Title XIX) Plan
			 for Alabama provides for medically necessary nursing facility services,
			 rendered in a facility which meet the licensure requirements of the Department
			 of Public Health and the certification requirements of Title XIX and XVIII of
			 the Social Security Act and complies with all other applicable state and
			 federal laws and regulations and with accepted professional standards and
			 principles that apply to professionals providing services.
(2) Nursing facilities must be administered
			 in a manner that enables them to use their resources effectively and
			 efficiently to attain or maintain the highest practicable physical, mental, and
			 psychosocial well-being of each resident.
(3) Nursing facilities must comply with Title
			 VI of the Civil Rights Act of 1964, the Federal Age Discrimination Act, Section
			 504 of the Rehabilitation Act of 1973 and with the Disabilities Act of
			 1990.
(4) Nursing facilities must
			 maintain identical policies and practices regarding transfer, discharge and
			 covered services for all residents regardless of source of payment.
(5) Nursing facilities must have all beds in
			 operation certified for Medicaid participation.
(6) Nursing facilities must be certified for
			 Medicare Title XVIII as a condition of participation in the Alabama Medicaid
			 Program.
(7) For nursing facilities
			 participating in Medicaid two agreements must be made by representatives of the
			 nursing facilities. These agreements outline the methods by which nursing
			 facility care is rendered to Medicaid patients. These two documents are
			 entitled Provider Agreement and Nursing Facility/Resident Agreement.
(a) The Provider Agreement is executed
			 between the nursing facility and the Alabama Medicaid Agency and details the
			 requirements imposed on each party to the agreement. It is also the document
			 which requires the execution of the Nursing Facility/Resident
			 Agreement.
(b) The Nursing
			 Facility/Resident Agreement is executed between the nursing facility
			 representative and the patient or his personal representative and details the
			 requirements imposed on each party to the agreement. This agreement must be
			 executed for each resident on admission and annually thereafter. If the
			 liability amount changes for the resident or if there are policy changes, the
			 agreement must be signed and dated as these changes occur. Two copies of the
			 agreement will be prepared; one shall be given to the resident or personal
			 representative and one shall be retained by the nursing facility.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.03 - Enrollment And Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All nursing facilities that desire to
			 enroll and participate in the Alabama Title XIX Medicaid nursing facility
			 program and to receive Medicaid payment for services provided for Medicaid
			 residents must submit the following requirements:
(a) Possess certification for Medicare Title
			 XVIII.
(b) Submit a budget to the
			 Alabama Medicaid Agency Provider Reimbursement Division for the purpose of
			 establishing a per diem rate.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.04 - Covered And Noncovered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Services included in basic (covered)
			 nursing facility charges.
(a) All nursing
			 services to meet the total needs of the resident including treatment and
			 administration of medications ordered by the physician.
(b) Personal services and
(c) Room (semiprivate or ward accommodations)
			 and board, including special diets and tubal feeding necessary to provide
			 proper nutrition. This service includes feeding residents unable to feed
			 themselves.
(d) All services
			 and
(e) Bed and bath
			 linens.
(f) Nursing and
			 treatment
(g) Safety and treatment
			 equipment such as bed rails, standard walkers, standard wheelchairs,
			 intravenous administration stands, suction apparatus, oxygen concentrators and
			 other items generally provided by nursing facilities for the general use of all
			 residents.
(h) Materials for
			 prevention and treatment of bed sores.
(i) Medically necessary over-the-counter
			 (non-legend) drug products ordered by a physician, with the exception of
			 over-the-counter insulin covered under the Pharmacy program. Generic brands are
			 required unless brand name is specified in writing by the attending
			 physician.
(j) Laundry services of
			 personal apparel.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.05 - Reservation of Beds

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Payment for
			 Reservation of Beds in Long Term Care Facilities.
(a) Neither Medicaid patients, nor their
			 families, nor their sponsor, may be charged for reservation of a bed for the
			 first four days of any period during which a Medicaid patient is temporarily
			 absent due to admission to a hospital. Prior to discharge of the patient to the
			 hospital, the patient, the family of the patient or the sponsor of the patient
			 is responsible for making arrangements with the nursing home for the
			 reservation of a bed and any costs associated with reserving a bed for the
			 patient beyond the covered four day hospital stay reservation period. The
			 covered four day hospital stay reservation policy does not apply to:
1. Medicaid-eligible patients who are
			 discharged to a hospital while their nursing home stay is being paid by
			 Medicare or another payment source other than Medicaid;
2. Any non-Medicaid patients;
3. A patient who has applied for Medicaid but
			 has not yet been approved; provided that if such a patient is later
			 retroactively approved for Medicaid and the approval period includes some or
			 all of the hospital stay, then the nursing home shall refund that portion of
			 the bed hold reservation charge it actually received from the patient, family
			 of the patient or sponsor of the patient for the period that would have been
			 within the four covered days policy; or
4. Medicaid patients who have received a
			 notice of discharge for non-payment of service.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.06 - Therapeutic Leave

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Payments to
			 nursing facilities may be made for therapeutic leave visits to home, relatives,
			 and friends for up to six days per calendar quarter. A therapeutic leave visit
			 may not exceed three days. Visits may not be combined to exceed the three day
			 limit.
(2) Payments to ICF/IID
			 facilities for therapeutic visits are limited to 14 days per calendar
			 month.
(3) The nursing facility
			 must ensure that each therapeutically indicated visit by a patient to home,
			 relatives, or friends is authorized and certified by a physician.
(4) Medicaid shall not be responsible for the
			 record keeping process involving therapeutic leave.
(5) A nursing facility must provide written
			 notice to the resident and a family member or legal representative of the above
			 specifying the Medicaid policy upon a resident taking therapeutic leave and at
			 the time of transfer of a resident to a hospital.
Author:
Robin Arrington, Associate Director, LTC
				  Provider Recipient/Services Unit
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
42 C.F.R. §§ 401,
et
				  seq
.; 483.12.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.07 - Review Of Medicaid Residents

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Alabama Medicaid Agency or its
			 designated agent will perform a retrospective review of Medicaid nursing home
			 or ICF/IID facility residents' records to determine appropriateness of
			 admission. Refer to Rule
			 560-X-10-.11(3)(g)
			 of this Administrative Code for more information.
Rule
				  560-X-10-.06, Review of Medicaid
				  Residents, was renumbered to Rule as per certification filed August 11, 2003;
				  effective September 15, 2003.
Author:
Robin Arrington, Administrator, LTC
				  Provider/Recipient Services Unit
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§ 401,
et
				  seq
., 435.1009, 456.1.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.08 - Physician Certification

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 physician must perform the specific physician services required by state and
			 federal law.
(2) A physician is
			 defined in Section 1861R of the Social Security Act as a doctor of medicine or
			 osteopathy legally authorized to practice medicine and surgery in the state in
			 which he is performing services.
Author:
Dittra S. Graham, Administrator, LTC
				Program Management Unit
Rule
				  560-X-10-.07, Use of Physician
				  Extenders (Nurse Practitioners and Physician Assistants (PA) in Nursing
				  Facilities), was renumbered to Rule 560-X-10-.08, Physician Certification, as
				  per certification filed August 11, 2003; effective September 15,
				  2003.
Statutory Authority:
State Plan; Section 1861R
				  and Title XIX, Social Security Act; 42 C.F.R. §§ 401, et seq.,
				  491.2.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.09 - Reimbursement And Payment Limitations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Reimbursement will be made in accordance
			 with Chapter 22, Alabama Medicaid Administrative Code.
(2) Each nursing facility shall have a
			 payment rate assigned by Medicaid. The patient's available monthly income minus
			 an amount designated for personal maintenance (and in some cases amounts for
			 needy dependents and health insurance premiums) is first applied against this
			 payment rate and Medicaid then pays the balance.
(a) The nursing facility may bill the
			 resident for services not included in the per diem rate (noncovered charges) as
			 explained in this chapter.
(b)
			 Actual payment to the facility for services rendered is made by the fiscal
			 agent for Medicaid in accordance with the fiscal agent billing
			 manual.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.10 - Admission Criteria

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Guidelines for nursing facility admission criteria: The principal aspect of
			 covered care relates to the care rendered. The controlling factor in
			 determining whether a person is receiving covered care is the medical
			 supervision that the resident requires. Nursing facility care provides
			 physician and nursing services on a continuing basis. The nursing services are
			 provided under the general supervision of a licensed registered nurse. An
			 individual may be eligible for care under the following circumstances:
(a) The physician must state "I certify" need
			 for admission and continuing stay.
(b) Nursing care is required on a daily
			 basis.
(c) Nursing services are
			 required that as a practical matter can only be provided in a nursing facility
			 on an inpatient basis.
(d) Nursing
			 service must be furnished by or under the supervision of a RN and under the
			 general direction of a physician.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.11 - Establishment Of Medical Need

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Application of Medicare Coverage:
(a) Nursing
			 facility residents, either through age or disability, may be eligible for
			 Medicare coverage up to 100 days.
(b) Nursing facilities must apply for
			 eligible Medicare coverage prior to Medicaid coverage.
(c) Nursing facilities cannot apply for
			 Medicaid eligibility for a resident until Medicare coverage is
			 discontinued.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.12 - Utilization Review For ICF/IID

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An ICF/IID must comply with the
			 utilization review requirements contained in
			 42 C.F.R. §§
									456.350-456.438 ("Utilization
			 Review Requirements").
(2) Medicaid
			 or its designee will conduct retrospective audits to ensure the facility
			 complies with the Utilization Review Requirements. The ICF/IID must make
			 available to Medicaid or its designee such documents, records, and other
			 writings as are necessary to demonstrate compliance with the Utilization Review
			 Requirements.
(3) If an ICF/IID
			 fails to comply with the Utilization Review Requirements, Medicaid may take
			 appropriate action, including but not limited to provider education, recoupment
			 of the amount of payments made during the time which the ICF/IID did not comply
			 with the Utilization Review Requirements, or denial of payments for the new
			 admissions to the ICF/IID.
Rule
				  560-X-10-.11, Utilization Review,
				  was renumbered to Rule, Utilization Review for ICF/MR as per certification
				  filed August 11, 2003; effective September 15,
				  2003.
Author:
Robin Arrington, Associate Director, LTC
				  Provider/Recipient Services Unit
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; P.L. 92-603; 42 C.F.R. §§ 401,
et
				  seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.13 - Resident Medical Evaluation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The admitting or attending physician must
			 certify the necessity of admission of a resident to an intermediate care
			 facility and make a comprehensive medical evaluation, as described in Rule No.
			 560-X-10-.11(3)(d)3.
			 This evaluation will be maintained by the facility as part of the resident's
			 permanent records.
(2) Each
			 Medicaid resident in an intermediate care facility must have a written medical
			 plan of care established by his physician and periodically reviewed and
			 evaluated by the physician and other personnel involved in the individual's
			 care.
(3) For nursing facilities,
			 the resident must be seen by a physician at least once every 30 days for the
			 first 90 days from admission, and at least once every 60 days
			 thereafter.
(4) The physician's
			 care plan must include:
(a)
			 Diagnosis.
(b) Symptoms and
			 treatments.
(c)
			 Complaints.
(d)
			 Activities.
(e) Functional
			 level.
(f) Dietary.
(g) Medications.
(h) Plans for continuing care and discharge
			 as appropriate.
(i) Social
			 services.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.14 - Resident Rights

Current through Register Vol. 42, No. 9, June 28, 2024
The resident has a right to a dignified existence,
				self-determination, and communication with and access to persons and services
				inside and outside the facility. A facility must protect and promote the rights
				of each resident, specified in
				42 CFR
				483.10.
(1) Exercise of rights.
(a) The resident has the right to exercise
			 his or her rights as a resident of the facility and as a citizen or resident of
			 the United States.
(b) The resident
			 has the right to be free of interference, coercion, discrimination, or reprisal
			 from the facility in exercising his or her rights.
(c) In the case of a resident adjudged
			 incompetent by a court of competent jurisdiction, the rights of the resident
			 are exercised by the person appointed under state law to act on the resident's
			 behalf.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.15 - Nursing Aide Training

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 nursing facility must not use (on a full-time, temporary, per diem, or other
			 basis) any individual as a nurse aide in the facility on or after October 1,
			 1990, for more than four (4) months unless the individual has completed a
			 training and competency evaluation program, or a competency evaluation program,
			 approved by the state and is competent to provide nursing or nursing related
			 services.
(2) The Alabama
			 Department of Public Health will be responsible for the certification of the
			 Competency Evaluation programs and will establish and maintain a nurse aide
			 registry.
Author:
Dittra S. Graham, Administrator, LTC
				Program Management Unit
Rule
				  560-X-10-.13, Nursing Aide
				  Training, was renumbered to Rule 560-X-10-.15, as per certification filed
				  August 11, 2003; effective September 15,
				  2003.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§401, et seq.; 431; 483; OBRA-87
				  §§4201(a), 4211(a); OBRA-89 §6901(b)
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.17 - Medical Director

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 nursing facility shall retain, pursuant to a written agreement, a physician
			 licensed under state law to practice medicine or osteopathy, to serve as
			 medical director on a part-time or full-time basis as is appropriate for the
			 needs of the residents and the facility.
(a)
			 If the facility has an organized medical staff, the medical director shall be
			 designated by the medical staff with approval of the governing body.
(b) A medical director may be designated for
			 a single facility or multiple facilities through arrangements with a group of
			 physicians, a local medical society, a hospital medical staff, or through
			 another similar arrangement.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-10 - LONG TERM CARE › Section 560-X-10-.18 - Availability Of Nursing Facilities Accounting Records

Current through Register Vol. 42, No. 9, June 28, 2024
Availability of accounting records must be made available in
				compliance with chapter 22, Alabama Medicaid Administrative Code.
Author:
Dittra S. Graham, Administrator, LTC
				Program Management Unit
Rule
				  560-X-10-.16, Availability of
				  Nursing Facilities Accounting Records, was renumbered to Rule 560-X-10-.18, as
				  per certification filed August 11, 2003; effective September 15,
				  2003.
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §483.10; Omnibus Budget Reconciliation
				  Act of 1987.