reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-38 - AMBULATORY SURGICAL CENTER SERVICES › Section 560-X-38-.05 - Ambulatory Surgical Center Transfer Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
The ambulatory surgical centers shall have an effective
				procedure for the immediate transfer to a hospital of patients requiring
				emergency medical care beyond the capabilities of the center. The hospital
				shall have a provider contract with the Alabama Medicaid Agency. The center
				shall have a written transfer agreement with said hospital, and each physician
				performing surgery in the center shall have admitting privileges at said
				hospital. The center shall furnish the Alabama Medicaid Agency with evidence of
				such prior to its enrollment. Changes in this submitted information will also
				be made available to the Medicaid Agency.
Author:
Statutory Authority:
42 C.F.R.
				  §
											416.41.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-38 - AMBULATORY SURGICAL CENTER SERVICES › Section 560-X-38-.06 - Surgical Procedures Groups

Current through Register Vol. 42, No. 9, June 28, 2024
The surgical procedures shall be classified into separate
				payment groups. All procedures within the same payment group are reimbursed at
				a single rate. These rates are subject to adjustment by the Alabama Medicaid
				Agency. The group payment amount is lowest for Group One procedures and highest
				for Group Nine. A provider shall receive the lesser of the submitted charge or
				the designated group charge less the copay amount.
Author:
Solomon Williams, Associate Director,
				  Insitutional Services, Managed Care Division
Statutory Authority:
State Plan, Attachment 3-A;
				  42 C.F.R. §§405.310,
				  416.65.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-38 - AMBULATORY SURGICAL CENTER SERVICES › Section 560-X-38-.07 - Submission Of Claims

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Ambulatory surgical center services are treated as medical services. UB82 claim
			 forms shall be submitted for payment listing facility provider number, HCFA
			 Common Procedure Coding System (HCPCS) and ICD-9-CM diagnosis codes (dates
			 services prior and up to September 30, 2015) or ICD-10-CM diagnosis codes
			 (dates of services October 1, 2015 and forward).
(2) If one covered surgical procedure is
			 furnished to a Medicaid recipient in an operative session, payment shall be at
			 the lesser of the submitted charges, or 100 percent of the predetermined rate
			 for the procedure.
(3) If more than
			 one covered surgical procedure is furnished to a Medicaid recipient in a single
			 operative session, payment shall be made at the lesser of the submitted
			 charges, or at the full amount for the procedure with the higher predetermined
			 rate less the copay amount. Other covered surgical procedures furnished in the
			 same session will be reimbursed at the lesser of the submitted charges, or at
			 50 percent of the predetermined rate for each of the other
			 procedures.
Author:
Solomon Williams, Associate Director,
				  Institutional Services
Statutory Authority:
42 C.F.R. §
											416.120.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-38 - AMBULATORY SURGICAL CENTER SERVICES › Section 560-X-38-.08 - Patient Signature

Current through Register Vol. 42, No. 9, June 28, 2024
Refer to Chapter One of the
Alabama Medicaid
				Administrative Code
, Rule
				560-X-1-.18(5)(a),
				as amended.
Author:
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; Alabama Medicaid Agency Administrative Code.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-38 - AMBULATORY SURGICAL CENTER SERVICES › Section 560-X-38-.09 - Billing And Sending Statement To Eligible Alabama Medicaid Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
(1) No eligible
			 Alabama Medicaid recipient shall receive a bill or statement for covered
			 services or items once the recipient has been accepted as a Medicaid patient. A
			 recipient may be billed by the provider for noncovered services or
			 items.
(2) The provider may send a
			 notice to the recipient stating the recipient's claim is outstanding provided
			 the notice indicates in bold letters: "THIS IS NOT A BILL."
(3) It is the responsibility of the provider
			 to pursue any unpaid claim with the fiscal agent and/or Medicaid involving
			 Medicaid covered services.
(4) No
			 recipient is responsible for the difference between the covered charges billed
			 and the amount paid by Medicaid for covered charges. A provider agrees to
			 accept as payment in full the amount paid by Medicaid for covered services, and
			 further agrees to make no additional charge(s) for covered services to the
			 recipient, sponsor, or family of the recipient.
Author:
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-38 - AMBULATORY SURGICAL CENTER SERVICES › Section 560-X-38-.10 - Copayment. (Cost-Sharing)

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medicaid recipients are required to pay, and ambulatory surgery center
			 providers are required to collect, the designated copayment amount for each
			 visit. Refer to Rule
			 560-X-1-.25
General
Chapter for copay information.
(2) A provider may not deny services to any
			 eligible individual due to the individual's inability to pay the cost-sharing
			 amount imposed.
Author:
The prior wording "Outpatient Surgical Services" that
				  appears throughout Chapter 560-X-38 is changed to read "Ambulatory Surgical
				  Center Services," in compliance with federal requirements. This change was made
				  by the agency without giving public notice pursuant to
Code of Ala.
				  1975
, § 41-22-6, as amended in Act 86-472. Filed September
				  30, 1986.
Statutory Authority:
State Plan, Attachment
				  4.18-A; Title XIX, Social Security Act;
				  42 C.F.R. §§
											447.50,
				  447.55,
				  447.15.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-39 - EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) › Section 560-X-39-.01 - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) ESWL is a
			 covered benefit for treatment of kidney stones in the renal pelvis,
			 uretero-pelvic junction, and the upper one-third of the ureter.
(2) ESWL is
not
a covered
			 service for urinary stones of the bladder and the lower two-thirds of the
			 ureter.
Authors:
Charles A. Reasner, Luann C.
				McQueen
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42
				  C.F.R. §§482.11,
				  482.12,
				  482.22,
				  482.54.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-39 - EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) › Section 560-X-39-.02 - Facility Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In
			 order for the Alabama Medicaid Agency to reimburse the facility for ESWL
			 treatment, the facility must have a signed ESWL Contract with the
			 Agency.
(2) For ESWL treatment to
			 both kidneys during the same treatment period, Medicaid will pay the facility
			 one-and-a-half times the regular reimbursement rate for this
			 procedure.
(3) Repeat ESWL
			 treatments on the same recipient within a ninety-day period will be reimbursed
			 at half the regular reimbursement rate for this procedure.
(4) The ESWL reimbursement rate is an
			 all-inclusive rate for each encounter and all services rendered in conjunction
			 with the treatment (with the exception of the physician's and the
			 anesthesiologist's) are included in the rate, such as lab, x-ray, and
			 observation.
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-39 - EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) › Section 560-X-39-.03 - Physician Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) For
			 ESWL treatment to both kidneys during the same treatment period, Medicaid will
			 pay the surgeon one-and-a-half times the regular reimbursement rate for the
			 surgical procedure.
(2) For repeat
			 ESWL treatments on the same recipient within a ninety-day period, Medicaid will
			 reimburse the surgeon at half the regular reimbursement rate for the surgical
			 procedure.
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-39 - EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) › Section 560-X-39-.04 - Anesthesiologist Services

Current through Register Vol. 42, No. 9, June 28, 2024
Anesthesiologist services are not included in the facility's or
				physician's reimbursement rate and therefore can be billed separately.
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-39 - EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) › Section 560-X-39-.05 - Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(In order to participate in the Title XIX Medicaid Program as
				an ESWL provider, the following requirements must be met:
(a) Submit written request for
			 enrollment
(b) Submit documentation
			 that the lithotripsy machine is FDA approved
(c) Provide documentation to indicate the
			 lithotripsy machine is being operated under the authority of a valid
			 Certificate of Need (CON). Documentation can be a copy of the valid CON or a
			 copy of the contract between the provider of care and the holder of the CON.
Author:
Luann C. McQueen
Statutory Authority:
State Plan, Attachment
				  3.1-A, Page 1; Title XIX, Social Security Act;
				  42
				  C.F.R. §§482.11,
				  482.12,
				  482.22,
				  482.54.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-40 - OPTIONAL TARGETED CASE MANAGEMENT › Section 560-X-40-.01 - Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Optional
			 Targeted Case Management (TCM) Services - those services to mentally ill adults
			 (Target Group 1), intellectually disabled adults (Target Group 2), disabled
			 children (Target Group 3), foster children (Target Group 4), pregnant women
			 (Target Group 5), AIDS/HIV-positive individuals (Target Group 6), adult
			 protective service individuals (Target Group 7), individuals who meet the
			 eligibility criteria for the Home and Community Based Services (HCBS)
			 Technology Assisted Waiver for Adults (TAW) (Target Group 8), individuals who
			 meet the eligibility criteria for substance use disorders (Target Group 9), and
			 individuals who meet the criteria for Disabled Children and Severely Mentally
			 Ill (SMI) Adults High Intensity Care Coordination (Target Group 10), paid for
			 by the Alabama Medicaid Agency to assist Medicaid-eligible persons in gaining
			 access to needed medical, social, educational, and other services.
(2) Case Management Services Target Group 1
			 -Mentally Ill Adults - the population to be served consists of functionally
			 limited individuals age 18 and over with multiple needs who have been assessed
			 by a qualified professional and have been found to require mental health case
			 management. Such persons have a diagnosis included in the ICD-10 as appropriate
			 to date of service (other than intellectual/developmental disabilities, autism
			 spectrum disorder, organic mental disorder, traumatic brain injury or substance
			 abuse), impaired role functioning, and a documented lack of capacity for
			 independently accessing and sustaining involvement with needed
			 services.
(3) Individual Case
			 Managers for Mentally Ill Adults - professionals meeting the following
			 qualifications:
(a) At a minimum, Bachelor of
			 Arts or a Bachelor of Science degree, preferably in a human services related
			 field, or
(b) A registered nurse,
			 and
(c) Training in case management
			 curriculum provided or approved by the Alabama Department of Mental Health
			 (ADMH) and the Alabama Medicaid Agency.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-40 - OPTIONAL TARGETED CASE MANAGEMENT › Section 560-X-40-.02 - Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Providers of
			 case management services must meet the following requirements:
(a) CMSP for the mentally ill must be
			 certified by the Department of Mental Health as meeting the qualifications for
			 enrollment as a case management provider under the provision of
			 560-X-40-.01(6);
(b) CMSP for intellectually disabled adults
			 must meet the qualifications for enrollment as a case management provider under
			 the provision of
			 560-X-40-.01(7);
(c) CMSP for disabled children, foster
			 children, pregnant women, and AIDS/HIV-positive individuals, adult protective
			 service individuals, individuals who meet the eligibility criteria for the HCBS
			 Technology Assisted Waiver (TAW), for Adults and individuals who meet the
			 eligibility criteria for Substance Use Disorders, and for disabled children who
			 meet the requirements for Autism Spectrum Disorder (ASD), disabled children who
			 meet the requirements for Seriously Emotionally Disturbed (SED), and for adults
			 who meet the requirements for Severe Mentally Illness (SMI) - High Intensity
			 Care Coordination must meet the following criteria:
1. Demonstrated capacity to provide all core
			 elements of case management:
(i)
			 Assessment,
(ii) Care/services plan
			 development,
(iii)
			 Linking/coordination of services, and
(iv) Reassessment/follow-up.
2. Demonstrated case management
			 experience in coordinating and linking such community resources as required by
			 the target population.
3.
			 Demonstrated experience with the target population.
4. Administrative capacity to ensure quality
			 of services in accordance with state and federal requirements.
5. A financial management system that
			 provides documentation of services and costs.
6. Capacity to document and maintain
			 individual case records in accordance with state and federal
			 requirements.
7. Demonstrated
			 ability to assure a referral process consistent with Section 1902a(23), freedom
			 of choice of provider.
8.
			 Demonstrated capacity to meet the case management service needs of the target
			 population.
(d) Shall be
			 in full compliance with Title VI of the Civil Rights Act of 1964 and Section
			 504 of the Rehabilitation Act of 1973;
(e) Shall be in full compliance with
			 applicable federal and state laws and regulations.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-40 - OPTIONAL TARGETED CASE MANAGEMENT › Section 560-X-40-.03 - Description Of Covered Services, Limitations, And Exclusions (General)

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Reimbursement
			 is made only for services rendered pursuant to mentally ill adults,
			 intellectually disabled adults, disabled children, foster children, pregnant
			 women, AIDS/HIV-positive individuals, adult protective service individuals,
			 individuals who meet the eligibility criteria for the HCBS Technology Assisted
			 Waiver (TAW) for Adults and individuals who meet the eligibility criteria for
			 Substance Use Disorders, and individuals who meet the criteria for disabled
			 children with Autism Spectrum Disorder (ASD), disabled children with Seriously
			 Emotionally Disturbed (SED), and adults with Severe Mental Illness (SMI) - High
			 Intensity Care Coordination as defined in as defined in Rule No.
			 560-X-40-.01. Case management
			 services are those services which will assist Medicaid-eligible individuals in
			 gaining access to needed medical, social, educational, and other services. The
			 case manager shall accomplish these services through telephone contact with
			 clients, face-to-face contact with clients, telephone contact with collaterals,
			 and/or face-to-face contact with collaterals. The core elements of the service
			 shall include the following:
(a) Needs
			 assessment -- a written comprehensive assessment of the person's assets,
			 deficits, and needs. The following areas must be addressed when relevant:
1. Identifying information,
2. Socialization/recreational
			 needs,
3. Training needs for
			 community living,
4. Vocational
			 needs,
5. Physical needs,
6. Medical care concerns,
7. Social/emotional status,
8. Housing, physical environment,
			 and
9. Resource analysis and
			 planning.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-40 - OPTIONAL TARGETED CASE MANAGEMENT › Section 560-X-40-.04 - Payment Methodology For Covered Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Governmental providers will be paid on a
			 negotiated rate basis which will not exceed actual costs and which will meet
			 all requirements of OMB Circular A-87. Nongovernmental providers will be
			 reimbursed on a negotiated rate basis which will not exceed the upper
			 limitations of
			 42
			 C.F.R. Section 447.325. The following
			 documentation must be maintained in the recipient's record when billing for
			 services:
(a) There must be a current
			 comprehensive service plan which identifies the medical, nutritional, social,
			 educational, transportation, housing and other service needs which have not
			 been adequately accessed and a time frame to reassess service needs.
(b) Services must consist of at least one of
			 the following activities:
1. Establishment of
			 the comprehensive case file for development and implementation of an
			 individualized service plan to meet the assessed service needs of the
			 recipient;
2. Assisting the
			 recipient in locating needed service providers and making the necessary
			 linkages to assure the receipt of services identified in the service
			 plan;
3. Monitoring the recipient
			 and service providers to determine that the services received are adequate in
			 meeting the identified needs; or
4.
			 Reassessment of the recipient to determine services needed to resolve any
			 crisis situation resulting from changes in the family structure, living
			 conditions, or other events.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-40 - OPTIONAL TARGETED CASE MANAGEMENT › Section 560-X-40-.05 - Third Party Liability

Current through Register Vol. 42, No. 9, June 28, 2024
The CMSP shall make all reasonable efforts to determine if
				there is a liable third party source, including Medicare, and in the case of a
				liable third party source, utilize that source for payments and benefits prior
				to filing a Medicaid claim. Third party payments received after billing
				Medicaid for service for a Medicaid recipient shall be refunded to the Alabama
				Medicaid Agency.
Author:
Willie Johnson
Statutory Authority:
42 C.F.R. Part 433;
				  §1915(g), Social Security Act; State Plan for Medical Assistance,
				  Attachment 3.1-A, Supplement 1; OMB No. 0939-0193.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-40 - OPTIONAL TARGETED CASE MANAGEMENT › Section 560-X-40-.06 - Payment Acceptance

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Payment made by the Alabama Medicaid Program to a CMSP shall be considered
			 payment in full for covered services rendered.
(2) No Medicaid recipient shall be billed for
			 covered Medicaid services.
(3) No
			 person or entity, except a potential third party source, shall be billed for
			 covered Medicaid services.
Author:
Willie Johnson
Statutory Authority:
42 C.F.R.,
				  §447.15; §1915 (g), Social Security
				  Act; State Plan for Medical Assistance, Attachment 3.1-A, Supplement 1; OMB No.
				  0939-0193.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-40 - OPTIONAL TARGETED CASE MANAGEMENT › Section 560-X-40-.07 - Confidentiality

Current through Register Vol. 42, No. 9, June 28, 2024
The CMSP shall not use or disclose, except to duly authorized
				representatives of federal or state agencies, any information concerning an
				eligible recipient, except upon the written consent of the recipient, his
				attorney, or his guardian, or upon subpoena from a court of appropriate
				jurisdiction.
Author:
Willie Johnson
Statutory Authority:
42 C.F.R.,
				  §§431.300,
et
seq
.; §1915(g),
				  Social Security Act; State Plan for Medical Assistance, Attachment 3.1-A,
				  Supplement 1; OMB No. 0939-0193.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-40 - OPTIONAL TARGETED CASE MANAGEMENT › Section 560-X-40-.08 - Records

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The CMSP shall
			 make available to the Alabama Medicaid Agency at no charge, all information
			 describing services provided to eligible recipients and shall permit access to
			 all records and facilities for the purpose of claims audit, program monitoring,
			 and utilization review by duly authorized representatives of federal and state
			 agencies. Complete and accurate medical/psychiatric and fiscal records which
			 fully disclose the extent of the service shall be maintained by the CMSP. Said
			 records shall be retained for the period of time required by state and federal
			 laws.
(2) CMSP records must contain
			 documentation of:
(a) Name of
			 recipient;
(b) Dates of
			 services;
(c) Name of provider
			 agency and person providing services;
(d) Nature, extent or units of services
			 provided;
(e) Places of service.
Author:
Willie Johnson
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.01 - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Inpatient
			 psychiatric services for recipients under age 21 are covered services when
			 provided:
(a) Under the direction of a
			 physician,
(b) By a psychiatric
			 hospital enrolled as a Medicaid provider in accordance with Rule No.
			 560-X-41-.02; OR
(c) By a psychiatric residential treatment
			 facility (PRTF) which is accredited by the Joint Commission on Accreditation of
			 Healthcare Organizations (JCAHO), the Commission on Accreditation of
			 Rehabilitation Facilities (CARF), the Council on Accreditation of Services for
			 Families and Children (COA), or by other accrediting organization with
			 comparable standards that is recognized by the State;
(d) Before the recipient reaches age 21 or,
			 if the recipient was receiving services immediately before he/she reached age
			 21, before the earlier of:
(1) the date
			 he/she no longer requires the services,
(2) the date he/she reaches age 22,
			 or
(3) the expiration of covered
			 days as limited in (2) below, and
(e) To a recipient who is admitted to and
			 remains in the facility for the course of the hospitalization; and
(f) As certified in writing to be necessary
			 in the setting in which it will be provided in accordance with
			 42 CFR
			 441.152.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.02 - Conditions Of Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
Hospitals:
(a) In order to
			 participate in the Title XIX Medicaid program and to receive Medicaid payment
			 for inpatient psychiatric services for individuals under age 21, a provider
			 must meet the following conditions:
1. Be
			 certified for participation in the Medicare/Medicaid program;
2. Be licensed as an Alabama psychiatric
			 hospital in accordance with current rules contained in the Alabama
			 Administrative Code Chapter 420-5-7. State hospitals which do not require
			 licensing as per state law are exempt from this provision (
Code of
			 Ala. 1975
, Section
			 22-50-1, et seq.);
3. Be accredited by the Joint Commission on
			 Accreditation of Healthcare Organizations;
4. Have a distinct unit for children and
			 adolescents;
5. Have a separate
			 treatment program for children and adolescents;
6. Be in compliance with Title VI and VII of
			 the Civil Rights Act of 1964 Section 504 of the Rehabilitation Act of 1973, and
			 with the Age Discrimination Act of 1975.
7. Execute an Alabama Medicaid Provider
			 Agreement for participation in the Medicaid program;
8. Submit a written description of an
			 acceptable utilization review (UR) plan currently in effect; and
9. Submit a budget of costs for medical
			 inpatient services for its initial cost reporting period, if a new provider.
Application by Alabama psychiatric hospitals for participation
				in the Medicaid program shall be made to the appropriate address indicated in
				the Provider Manual.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.03 - Inpatient Psychiatric Benefits

Current through Register Vol. 42, No. 9, June 28, 2024
(1) For purposes of this chapter, an
			 inpatient is a person who has been admitted to a psychiatric facility for bed
			 occupancy for purposes of receiving inpatient psychiatric services.
(2) The number of days of care charged to a
			 recipient for inpatient psychiatric services is always 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
			 facility uses a different definition of day for statistical or other
			 purposes.
(3) Medicaid covers the
			 day of admission, but not the day of discharge.
(4) Therapeutic visits away from the
			 psychiatric hospital to home, relatives, or friends are authorized if certified
			 by the attending physician as medically necessary in the treatment of the
			 recipient.
(a) Payments for therapeutic
			 visits away from the hospital are limited to no more than two visits with each
			 visit not exceeding three days in duration per 60 calendar days per admission
			 per recipient. The first calendar day begins with the day of
			 admission.
(b) Therapeutic visits
			 away from the hospital exceeding three days in duration are not covered and no
			 part of these visits may be billed to Medicaid.
(c) Therapeutic visit records will be
			 reviewed retrospectively by the PA Unit. Payments for therapeutic visits in
			 excess of the amount as described in (4)(a) above will be recouped.
(d) This policy applies only to visits away
			 from the psychiatric hospital. Therapeutic visits away from the PRTF are not
			 limited by this policy.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.04 - Certification Of Need For Inpatient Hospital Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Certification of need for inpatient
			 hospital services is a determination which is made by the certifying team as
			 specified in (4) below regarding the Medicaid recipient's treatment needs for
			 admission to the facility.
(2) The
			 appropriate team must certify that:
(a)
			 Ambulatory care resources available in the community do not meet the treatment
			 needs of the recipient;
(b) Proper
			 treatment of the recipient's psychiatric condition requires services on an
			 inpatient basis under the direction of a physician; and
(c) The services can reasonably be expected
			 to improve the recipient's condition or prevent further regression so that the
			 services will no longer be needed.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.05 - Medical, Psychiatric, And Social Evaluations

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 or staff
			 physician must make a medical evaluation of each recipient's need for care in
			 the facility and appropriate professional personnel must make a psychiatric and
			 social evaluation. The psychiatric evaluation must be completed within 60 days
			 of admission. The specific requirements for psychiatric medical records may be
			 found at
			 42
			 CFR, 482.61.
(2) Each medical evaluation must include:
(a) Diagnosis within the ICD-9 range of
			 290-316 (dates services prior and up to September 30, 2015} or ICD-10 range of
			 F01.50 - F69, F80.0 - F99, G44.209, H93.25, R37, R45.1 - R45.2, R45.5 - R45.82,
			 R480, Z87.890 (dates of services October 1, 2015 and forward.
(b) Summary of present medical
			 findings,
(c) Medical
			 history,
(d) Mental and physical
			 functional capacity,
(e) Prognosis,
			 and
(f) A recommendation by a
			 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.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.06 - Active Treatment

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Inpatient psychiatric services are covered by Medicaid only if they involve
			 active treatment which means implementation of a professionally developed and
			 supervised individual plan of care that is:
(a) Developed and implemented no later than
			 14 working days after admission, and
(b) Designed to achieve the recipient's
			 discharge from inpatient status at the earliest possible time.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.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:
(a) 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. §§
									456.201 through
			 42 C.F.R.
			 456.245;
(b) Maintain recipient information required
			 for UR under 42 C.F.R.
			 §
									456.211, which shall include the
			 certification of need for service and the plan of care; and
(c) Provide a copy of the UR plan and any
			 subsequent revisions to Medicaid for review and approval.
Authors:
Gwen Williams, Vicki W.
				Huff
Statutory Authority:
42 C.F.R.
				  §§456.200 through
				  456.245.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.08 - Payment

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Payment for
			 inpatient services provided by psychiatric hospitals shall be the per diem rate
			 established by Medicaid for the hospital which is based on the Medicaid cost
			 report and provisions of Chapter 23 of the
Alabama Medicaid
			 Administrative Code
.
(2) Providers are required to file a complete
			 uniform Medicaid cost report for each fiscal year. One copy of this report must
			 be received by Medicaid within three months after the Medicaid cost report
			 year-end.
(3) Hospitals that
			 terminate participation in the Medicaid program must provide a final cost
			 report within 120 days of the date of termination of participation.
(4) 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.
(5) Medicaid pays for residential treatment
			 services provided by PRTFs according to the per diem rate established in the
			 placement agreement between the PRTF and the contracting state agency (DHR,
			 DYS, DMH, DCA).
(6) Providers
			 should not send recipients bills or statements for covered services once that
			 recipient has been accepted as a Medicaid patient. Providers may send a notice
			 to the recipient stating their claim is still outstanding if the notice
			 indicates in bold print, "
THIS IS NOT A BILL
". Providers are
			 responsible for follow-up with the fiscal agent recipient or Medicaid on any
			 billing problems or unpaid claims. Providers may not bill the recipient for the
			 difference between charges billed and the amount paid by Medicaid. Providers
			 agree to accept the amount paid by Medicaid as payment in full. Providers may
			 bill recipients only for the allowable copay amount, for services not covered
			 by Medicaid, or when benefits have been exhausted.
Author:
Solomon Williams, Associate Director,
				  Institutional Services
Statutory Authority:
State Plan, Attachment
				  4.19-A; 42 C.F.R. § 413.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.09 - Inpatient Review Criteria

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 All patients seeking admission to a psychiatric hospital must require
			 psychiatric services that can only be provided on an inpatient basis. These
			 psychiatric services must involve implementation of a professionally developed
			 and supervised individualized plan of care.
(2) The inpatient admission criteria utilized
			 by Medicaid require a documented need for inpatient psychiatric services. A
			 patient seeking admission to a psychiatric hospital must meet at least one of
			 the following criteria:
(a) Inappropriate
			 performance of activities of daily living as evidenced by:
1. inappropriate hygiene or
			 grooming;
2. psychomotor agitation
			 or retardation;
3. severe
			 disturbances in appetite or sleep.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.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.
(4)
			 For an individual who is a Medicaid recipient at the time of admission, the
			 attending physician must sign a Psychiatric Admission for including the medical
			 necessity of the admission.
(4) 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.
(5) 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-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.11 - Inpatient Continued Stay Reviews

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The provider's interdisciplinary
			 treatment team is responsible for performing continued stay reviews on
			 recipients who require continued inpatient hospitalization. These continued
			 stay review dates will be determined by the PA Unit following an evaluation of
			 the information submitted on the Psychiatric Admission form.
(2) Continued stay updates must include:
(a) Master Treatment Plan and subsequent
			 changes;
(b) Utilization review
			 worksheet;
(c) Physician's progress
			 notes, nursing progress notes and, if requested, social worker's progress notes
			 (individual and family sessions, discharge planning). The PA Unit may request
			 this information when documentation included in (a) and (b) is insufficient to
			 justify the continued hospital stay.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.12 - Recertification Of Need For Inpatient Care

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Recertification of need for inpatient
			 care must be made on the PSY-3 form at least every 60 days after admission by
			 the patient's attending physician and filed in the patient's medical record.
Author:
Lynn Sharp, Associate Director, Policy
				Development Unit
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42
				  C.F.R. §456.160.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.13 - Certification Of Need For Residential Treatment Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Recipients seeking admission to a
			 psychiatric residential treatment facility (PRTF) shall require continuous and
			 active psychiatric treatment and care in a facility which meets the standards
			 in 560-X-41-.02(2)
			 (a-b).
(2) Recipients seeking
			 admission to a PRTF must meet at least one of the admission criteria listed in
			 560-X-41-.09(2)
			 (a-d).
(3) For elective or
			 non-emergency admissions of individuals who are Medicaid-eligible when admitted
			 to the PRTF, a certification of the need for services shall be performed by an
			 independent team that:
(a) Includes a
			 physician;
(b) Has competence in
			 diagnosis and treatment of mental illness (preferably in child psychiatry);
			 and
(c) Has knowledge of the
			 individual's situation.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.14 - Residential Continued Stay Reviews

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The PRTFs interdisciplinary team shall be
			 responsible for performing continued stay reviews on recipients who require
			 continuous residential services.
(2) Recipients requiring continued stays in
			 PRTFs must meet at least one of the criteria listed in
			 560-X-41-.09(4)
			 (a-f).
(3) The plan of care shall
			 be reviewed at least every 30 days by the interdisciplinary team to:
(a) Determine that services are/were
			 medically necessary; and
(b)
			 Recommend changes in the plan as indicated by the recipient's overall
			 adjustment to treatment.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.15 - Recertification Of Need For Residential Services

Current through Register Vol. 42, No. 9, June 28, 2024
Recertification of need for residential services shall be noted
				on the recipient's plan of care by the attending physician at least every 30
				days.
Author:
Lynn Sharp, Associate Director,
				Institutional Services
Statutory Authority:
State Plan, Attachment
				  3.1-A, pp. 7, 7.16; 42 CFR, Part 441, Subpart D
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-41 - PSYCHIATRIC FACILITIES FOR INDIVIDUALS UNDER AGE 21 › Section 560-X-41-.16 - Reporting Of Deaths And Serious Occurrences

Current through Register Vol. 42, No. 9, June 28, 2024
(1) PRTFs seeking enrollment with Medicaid
			 must meet the requirements of 42 CFR, Part 483, Subpart G, regarding the
			 reporting of serious occurrences.
(2) PRTFs shall submit a written attestation
			 of compliance with the federal rules at the time of enrollment. The written
			 attestation must be signed by an individual who has the legal authority to
			 obligate the facility.
(3) At a
			 minimum, the attestation shall include:
(a)
			 The name, address, telephone number of the facility, and provider number (if
			 applicable);
(b) The signature and
			 title of the individual who has the legal authority to obligate the
			 facility;
(c) The date the
			 attestation is signed;
(d) A
			 statement certifying that the facility currently meets all of the requirements
			 of 42 CFR, Part 483, Subpart G, governing the use of restraint and
			 seclusion;
(e) A statement
			 acknowledging the right of the State Survey Agency (or its agents) and, if
			 necessary, the Centers for Medicare and Medicaid Services (CMS), to conduct an
			 on-site survey at any time to validate the facility's compliance with the
			 requirements of the rule, to investigate complaints lodged against the
			 facility, or to investigate serious occurrences;
(f) A statement that the facility will notify
			 Medicaid if it no longer complies with the requirements of the rule;
			 and
(g) A statement that the
			 facility will submit a new attestation of compliance in the event the
			 individual who has the legal authority to obligate the facility is no longer in
			 such position.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.01 - ICF/IID Reimbursement - Preface

Current through Register Vol. 42, No. 9, June 28, 2024
This regulation states the Medicaid policy regarding ICF/IID
				reimbursement and establishes the accepted procedures whereby reimbursement is
				made to these providers. Because of the length and complexity of this Chapter,
				it has been divided into the above sections to facilitate its
				utilization.
Author:
Robin Arrington, Associate Director, LTC
				  Provider/Recipient Services Unit
Statutory Authority:
Code of Ala.
				  1975
, §
										41-22-2.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.02 - Introduction

Current through Register Vol. 42, No. 9, June 28, 2024
(1) This Chapter of
			 the Alabama Medicaid Regulations has been promulgated by the Alabama Medicaid
			 Agency (Medicaid) for the guidance of providers of Medicaid ICF/IID care. This
			 Chapter is applicable to those providers classified as ICF/IID.
(2) The Alabama Medicaid Program is
			 administered by Medicaid under the direction of the Governor's Office.
			 Reimbursement principles for ICF/IID providers are outlined in the following
			 sections of this Chapter. These principles, hereinafter referred to as
			 "Medicaid Reimbursement Principles," are a combination of generally accepted
			 accounting principles, principles included in the State Plan, Medicare (Title
			 XVIII) Principles of Reimbursement, and principles and procedures promulgated
			 by Medicaid to provide reimbursement of provider costs which must be incurred
			 by efficiently and economically operated ICF/IIDs. These principles are not
			 intended to be all inclusive, and additions, deletions, and changes to them
			 will be made by Medicaid, as required. Providers are urged to familiarize
			 themselves fully with the following information, as cost reports must be
			 submitted to Medicaid in compliance with this regulation.
(3) If this regulation is silent on a given
			 point, Medicaid will normally rely on Medicare (Title XVIII) Principles of
			 Retrospective Reimbursement and, in the event such Medicare principles provide
			 no guidance, Medicaid may impose other reasonability tests. The tests include
			 but are not limited to such tests as:
(a)
			 Does the cost as reported comply with generally accepted accounting
			 principles?
(b) Is the cost
			 reasonable on its own merit?
(c)
			 How does the cost compare with that submitted by similarly sized homes
			 furnishing like levels of care?
(d)
			 Is the cost related to resident care and necessary to the operations of an
			 ICF/IID facility?
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.03 - Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
Accrual
			 Method of Accounting
- Revenues must be allocated to the accounting
			 period in which they are earned and expenses must be charged to the period in
			 which they are incurred. This must be done regardless of when cash is received
			 or disbursed.
(2)
Cash Basis
			 of Accounting
- Revenues and expenditures are recognized when cash is
			 received and disbursed.
(3)
Adjusted Reported Costs
- The net reported costs from Schedule B,
			 Column 3, of the cost report adjusted, as required, for unallowable costs, and
			 cost recovery items.
(4)
Medicaid
- The Alabama Medicaid Agency.
(5)
Medicaid Reimbursement
			 Principles
- A combination of generally accepted accounting principles,
			 principles included in the State Plan, Medicare (Title XVIII) Principles of
			 Reimbursement, and procedures and principles promulgated by Medicaid to provide
			 reimbursement of provider costs which must be incurred by efficiently and
			 economically operated ICF/IID facility.
(6)
Allowable Costs
- The costs
			 of a provider of ICF/IID services which must be incurred by an efficiently and
			 economically operated facility and which are not otherwise disallowed by the
			 reimbursement principles established under and incorporated into this
			 Chapter.
(7)
Approved Bed
			 Rate
- The Medicaid rate paid to facilities for approved beds. (See Rule
			 560-X-42-.04 for
			 computation.)
(8)
Chapter
- This Chapter of the
Alabama Medicaid Agency
			 Administrative Code
.
(9)
Class
- Grouping formed
			 according to type of facility. Medicaid classes to which this Chapter applies
			 are:
(a) Institutionally based, larger than 15
			 beds;
(b) Institutionally based
			 with at least four (4) but no more than fifteen (15) beds.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.04 - Medicaid Per Diem Rate Computation Methodology

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All ICF/IID providers will be grouped
			 into two (2) functional categories:
(a)
			 ICF/IIDs larger than 15 beds.
(b)
			 ICF/IIDs (15 beds or less).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-42 - ICF/MR REIMBURSEMENT › Section 560-X-42-.05 - Medicaid Inflation Index

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 The Medicaid Inflation Index will be used in lieu of budgeting to adjust
			 certain actual allowable costs from the reporting period for the purpose of
			 computing the prospective per diem rate payable and for such other adjustments
			 as may be specified in this chapter.
(2) The Medicaid Inflation Index shall be
			 based upon the economic indicators as published by Data Resources, Inc. (DRI)
			 for the Department of Health and Human Services. The indicators shall be the
			 Market Basket Index of Operating Costs - Skilled Nursing Facility, which are
			 published quarterly, whereas the Medicaid fiscal year for cost reporting and
			 rate setting purposes ends on September 30th. Therefore, the Medicaid Inflation
			 Index for a rate period will be the DRI Index for the twelve-month period
			 ending on the calendar quarter for which the index has been published or made
			 available at October 1st of each year.
(3) The Medicaid Inflation Index will be
			 established each October 1st for the current fiscal year based upon the
			 information then available to Medicaid and will not be adjusted again until the
			 next following October 1st, regardless of any later release of revised or
			 additional information relevant to the determination of the index.
Author:
Susan Mims
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act;
				  42 C.F.R.
				  §§447.250 - .255.