reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.12 - Over-The-Counter Medications

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Over-the-counter medications/products require a signed prescription from a
			 physician or other practitioner legally licensed by the State of Alabama to
			 prescribe the drugs authorized under the program.
(2) Over-the-counter medications/products
			 must be dispensed by a licensed Medicaid pharmacist in accordance with state
			 and federal laws as stated in Rule
			 560-X-16-.01.
(3) Over-the-counter medications/products
			 will be reimbursed as stated in Rule No.
			 560-X-16-.06 Reimbursement for
			 Covered Drugs.
(4) Over-the-counter
			 medications/products will be covered in long term care facilities as stated in
			 Rule No. 560-X-16-.05 Long Term Care
			 Facilities.
Author:
Stephanie Frawley, CPhT, Pharmacy
				Services
Statutory Authority:
State Plan, Attachment
				  3.1-A; Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.13 - Claim Form Acquisition

Current through Register Vol. 42, No. 9, June 28, 2024
The Medicaid fiscal agent will furnish claim forms upon
				request.
Author:
Statutory Authority:
The Alabama Medicaid Agency
				  Contract with Fiscal Agent for payment of claims.
The
				repealed version of this section by
				Alabama
				Administrative Monthly Volume XLII, Issue No. 08, May 31, 2024,
				filed May 20, 2024 is not yet
				available.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.15 - Claim Filing Limitations

Current through Register Vol. 42, No. 9, June 28, 2024
For claim filing limitations, refer to Chapter 1, Rule
				560-X-1-.17.
Author:
Sam T. Hardin
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-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.16 - Automated Billing System

Current through Register Vol. 42, No. 9, June 28, 2024
Refer To Rules
				560-X-1-.17 And
				560-X-1-.18.
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-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.17 - Restriction Of Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
The recipient may be placed on restriction who has abused
				and/or over-utilized pharmacy and/or physician services. The procedure to place
				an individual on restriction and limit the individual to a pharmacy and a
				physician is stated in Chapter 4 on S/UR in this Code.
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-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.18 - Pharmacy Peer Review Committees

Current through Register Vol. 42, No. 9, June 28, 2024
Composition and selection is as stated in Chapter 2 of this
				Code.
Author:
Larry A. Tatum
Statutory Authority:
State Plan, Attachment
				  3.1A; Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.
The
				repealed version of this section by
				Alabama
				Administrative Monthly Volume XLII, Issue No. 08, May 31, 2024,
				filed May 20, 2024 is not yet
				available.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.19 - Pricing Information

Current through Register Vol. 42, No. 9, June 28, 2024
The Medicaid Physicians Program shall approve the rate of
				reimbursement for injectable drugs (for physicians or outpatient hospitals).
				The actual research and price determination is made by the fiscal agent as set
				forth in the fiscal agent contract. The drug pricing file is furnished to the
				fiscal agent who shall update and utilize for pharmacy claims processing within
				twenty-four (24) hours of receipt for pharmacy claims.
Authors:
Sam T. Hardin, Larry A.
				Tatum
Statutory Authority:
State Plan, Attachments
				  3.1A, 4.18B; Title XIX, Social Security Act; 42 C.F.R. §§401, et
				  seq., 447.331; Omnibus Budget Reconciliation Act of 1990 (Public
				  Law 101-508).
The
				repealed version of this section by
				Alabama
				Administrative Monthly Volume XLII, Issue No. 08, May 31, 2024,
				filed May 20, 2024 is not yet
				available.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.20 - Quantity Limitations

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Prescriptions should be written to provide a sufficient amount of medication
			 necessary for the duration of the illness or an amount sufficient to cover the
			 interval between physician's visits. A prescription shall not be split into
			 small units and submitted as separate claims in order to obtain additional
			 dispensing fees.
(2) The quantity
			 for which a prescription is written should not exceed a maximum of eleven
			 refills for non controlled prescriptions or five refills for Control III-V
			 prescriptions. Claims for prescription refills beyond eleven refills for non
			 controlled prescriptions or five refills for Control III-V prescriptions shall
			 be denied.
(3) Quantities (units)
			 of drugs prescribed by a physician shall not be arbitrarily changed by a
			 pharmacist except by authorization of the physician.
(a) The pharmacist must contact the
			 prescribing physician for authorization to reduce the quantity of any Medicaid
			 prescription.
(b) Authorization to
			 reduce the units of a prescription must be noted on the prescription form by
			 the pharmacist.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.21 - Prescription Refill

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Prescriptions will have a maximum of no more than eleven (11) refills for non
			 controlled prescriptions or five (5) refills for Control III-V prescriptions
			 authorized.
(2) Physicians are
			 urged to designate refills or indicate non-refills on all Title XIX (Medicaid)
			 prescriptions. If the physician does not designate refills or indicates no
			 refill on the prescription, then the non-refill status will apply. If the
			 physician grants oral authorization to refill a previously undesignated or
			 non-refillable prescription, the pharmacist must indicate each authorization on
			 the prescription.
(3) If a
			 prescription is refilled, the date upon which the prescription is refilled must
			 appear on the prescription.
(4) All
			 prescriptions should be refilled only in quantities commensurate with dosage
			 schedule and refill instructions.
(5) Violations of these policies may result
			 in unauthorized charges for which the pharmacy may be held liable and/or
			 cancellation of the pharmacy vendor agreement.
Author:
Kelli Littlejohn, RPh, Director, Pharmacy
				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-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.22 - Signature Requirement For Manual Pharmacy Claim Form

Current through Register Vol. 42, No. 9, June 28, 2024
For recipient and provider signature requirements, please refer
				to Rule 560-X-1-.18.
Authors:
Janet B. Young; Larry A.
				Tatum
Statutory Authority:
State Plan, Attachments
				  3.1A, 4.18B; Title XIX, Social Security Act; 42 C.F.R. §§401, et
				  seq., 447.331; Omnibus Budget Reconciliation Act of 1990 (Public
				  Law 101-508).
The
				repealed version of this section by
				Alabama
				Administrative Monthly Volume XLII, Issue No. 08, May 31, 2024,
				filed May 20, 2024 is not yet
				available.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.23 - Drug Utilization Review (DUR) - General

Current through Register Vol. 42, No. 9, June 28, 2024
In accordance with the Medicaid Drug Amendments contained in
				the Omnibus Budget Reconciliation Act of 1990, (Public Law
				101-508), the following shall apply:
(1) The Medicaid Agency shall provide, by not
			 later than January 1, 1993, for a Drug Utilization Review (DUR) Program for
			 covered outpatient drugs in order to assure that prescriptions are appropriate,
			 medically necessary, and are not likely to result in adverse medical
			 results.
(2) The DUR Program is
			 made up of the following components: Prospective Drug Utilization Review,
			 Retrospective Drug Utilization Review, and an educational program.
(3) The Alabama Medicaid Agency has
			 established a DUR Board. Board membership shall be composed of four practicing
			 physicians, four practicing pharmacists, two representatives from the state's
			 pharmacy schools, two representatives from the state's medical schools, and two
			 representatives from the Alabama Medicaid Agency with knowledge and experience
			 in:
(a) Clinically appropriate prescribing and
			 dispensing of covered outpatient drugs
(b) Monitoring of covered outpatient
			 drugs
(c) Drug use review,
			 evaluation and intervention
(d)
			 Medical quality assurance
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.24 - Prospective DUR

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Prospective DUR
			 (PRODUR) is required at the point of sale or distribution before each
			 prescription is filled or delivered to a Medicaid recipient. It must include
			 screening, patient counseling, and patient profiles.
(2) Screening - The review must include
			 screening for potential drug therapy problems as specified by the Alabama State
			 Board of Pharmacy. This includes screens for:
(a) Therapeutic duplication means the
			 prescribing and dispensing, where overlapping periods of drug administration
			 are involved and where such prescribing or dispensing is not medically
			 indicated, of:
(1) two or more doses of the
			 same drug,
(2) at least two drugs
			 from the same therapeutic class, or
(3) at least two drugs from different
			 therapeutic classes with similar pharmacological effects being used for the
			 same indication.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.25 - Retrospective DUR

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 retrospective DUR Program reviews, analyzes and interprets patterns of
			 recipient drug usage by applying criteria and standards, developed by the DUR
			 Board, against claims data through periodic examination to identify patterns of
			 fraud and abuse, gross overuse, and inappropriate or medically unnecessary
			 care. Cases of possible fraud and/or abuse shall be referred to the Medicaid
			 Program Integrity Division.
Author:
Statutory Authority:
State Plan, Page 74a; Title
				  XIX, Social Security Act;
				  42
				  CFR Section 440.120;
				  Public
				  Law 101-508.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.26 - Educational Program

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The purpose
			 of this program is to educate practitioners on common drug therapy problems to
			 improve prescribing and dispensing practices.
(2) Drug use criteria and standards,
			 established by the DUR Board shall be applied to the drug database after the
			 medication is dispensed. In instances where pharmaceutical use deviates from
			 the criteria and standards, the profile shall undergo further review and
			 possible intervention if appropriate.
(3) Educational program interventions
			 includes:
(a) Dissemination of information to
			 physicians and pharmacists in the State concerning the duties and powers of the
			 DUR Board and the basis for the standards used in assessing drug use.
(b) Written, oral, or electronic reminders
			 containing patient-specific or drug-specific information (or both) and
			 suggested changes in prescribing or dispensing practices.
(c) Face-to-face discussions, with follow up
			 discussions when necessary, between health care professionals expert in
			 appropriate drug therapy and selected prescribes and pharmacists who have been
			 targeted for educational intervention on optimal prescribing, dispensing, or
			 pharmacy care practices.
(d)
			 Intensified review or monitoring of selected prescribes or dispensers.
Author:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.27 - Preferred Drug List

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 Alabama Medicaid Agency will utilize a preferred drug list for determination of
			 drugs available for reimbursement under the Medicaid Program. For reimbursement
			 under the Medicaid Program, use of the Preferred Drug list is mandatory. Drugs
			 not included on the list may be available through the prior authorization
			 process. Medicaid shall strive to ensure any restriction on pharmaceutical use
			 does not increase overall health care costs to Medicaid.
(2) Over the counter drugs covered by
			 Medicaid will be considered preferred drugs for purposes of this rule. Over the
			 counter drugs will not appear on the preferred drug list.
(3) The Alabama Medicaid Agency will utilize
			 the Pharmacy and Therapeutics Committee to review and recommend drugs for the
			 Preferred Drug List. The Committee will consist of three clinical pharmacists
			 licensed to practice in the state of Alabama and at least five physicians
			 licensed to practice medicine in the state of Alabama. Physician members will
			 be appointed by the Medicaid Commissioner from a list of at least two nominees
			 for each position submitted by Medical Association of the State of Alabama.
			 Clinical pharmacist members will be nominated by the Alabama Pharmacy
			 Association and appointed by the Medicaid Commissioner; pursuant to state law
			 governing professional services. Members will serve staggered two-year terms
			 and may be reappointed to the Pharmacy and Therapeutics Committee for
			 additional terms.
(4) Drugs will be
			 considered for the preferred drug list based on the following:
(a) clinical efficacy
(b) side effect profiles
(c) appropriate usage
(d) cost
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.29 - Annual Report

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The DUR
			 Board must submit an annual report to the Medicaid Agency containing
			 information specified by the state. The Agency must submit, annually, a report
			 to the Secretary of Health and Human Services through the HCFA Regional Office
			 that incorporates the DUR Board Report. It must Include:
(a) A description of the nature and scope of
			 the prospective drug review program.
(b) A description of how pharmacies
			 performing prospective DUR without computers are expected to comply with the
			 statutory requirement for written criteria.
(c) Detailed information on the specific
			 criteria and standards in use.
(d)
			 A description of the steps taken by the State to include in the prospective and
			 retrospective DUR program drugs dispensed to residents of a nursing facility
			 that is not in compliance with approved drug regimen review
			 procedures.
(e) A description of
			 the actions taken by the State Medicaid agency and the DUR Board to ensure
			 compliance with the requirements for predetermined standards and with the
			 access to the predetermined standards requirement.
(f) A description of the nature and scope of
			 the retrospective DUR program.
(g)
			 A summary of the educational interventions used and an assessment of the effect
			 of these educational interventions on the quality of care.
(h) A description of the steps taken by the
			 State Agency to monitor compliance by pharmacies with the prospective DUR
			 counseling requirements contained in Federal and State laws and
			 regulations.
(i) Clear statements
			 of purpose that delineate the respective goals, objectives, and scopes of
			 responsibility of the DUR and surveillance and utilization review (SUR)
			 functions.
(j) An estimate of the
			 cost savings generated as a result of the DUR program. This report must
			 identify costs of DUR and savings to the Medicaid drug program attributable to
			 prospective and retrospective DUR.
Author:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.30 - Hospice Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Reimbursement for disease specific drugs related to the recipient's terminal
			 illness and drugs related to the terminal illness found on the Hospice
			 Palliative Drug List (HPDL) are included in the per diem for hospice covered
			 services and will not be reimbursed through the Medicaid Pharmacy Program. The
			 HPDL is on the agency website at
www.medicaid.alabama.gov
.
Author:
Kelli Littlejohn, RPh, Director,
				  Pharmacy Services
Statutory Authority:
Title XIX, Social Security
				  Act;
				  42 CFR Section
				  418.302; State Medical Manual; and State
				  Plan.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-16 - PHARMACEUTICAL SERVICES › Section 560-X-16-.31 - Hemophilia Management Standards Of Care

Current through Register Vol. 42, No. 9, June 28, 2024
In order to be paid for providing blood clotting factor to
				Alabama Medicaid recipients, the provider must agree to provide, at the
				minimum, the following clinically appropriate items and services to their
				patients with hemophilia and blood clotting factor-related diseases:
(1) Home or office delivery of blood clotting
			 factor and supplies. All shipments/delivery of clotting factor, including
			 overnight deliveries, must use appropriate cold chain management and packaging
			 practices to ensure proper temperature, drug stability, integrity, and efficacy
			 are maintained during shipment.
(2)
			 Educational materials and programs.
(a) The
			 provider shall develop a training library at each enrolled provider location
			 with materials for patient use, to include but not limited to, audio, video,
			 electronic, and written materials.
(b) The provider shall offer educational
			 materials to patient or family/caregiver at minimum at initiation of
			 participation with the provider, yearly during the in-home assessment, and upon
			 the request of Medicaid, the prescribing physician, or patient or
			 family/caregiver.
(c) Topics of
			 education shall include, but not be limited to, specific patient and
			 family/caregiver education aimed at preventing injury that would result in a
			 bleed, self-administration and reconstitution of blood clotting
			 products.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-17 - EYE CARE SERVICES › Section 560-X-17-.01 - Eye Care Services - General

Current through Register Vol. 42, No. 9, June 28, 2024
The information contained herein sets forth policies and
				procedures for providing eye care services under the Alabama Medicaid
				Program.
(1) Participation. Only
			 in-state and borderline out-of-state eye care services providers (within a
			 30-mile radius of the state line) who meet enrollment requirements are eligible
			 to participate in the Alabama Medicaid Program. The following information must
			 be included in a written enrollment request to Medicaid's Fiscal Agent,
			 Provider Enrollment Division:
(a)
			 Name
(b) Address
(c) Specialty Provider Type
(d) Social Security Number
(e) Tax Identification Number
(f) Medical or Business License Number, as
			 applicable
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-17 - EYE CARE SERVICES › Section 560-X-17-.02 - Physician Services For Diseases, Injuries, Or Congenital Defects

Current through Register Vol. 42, No. 9, June 28, 2024
(1) If medically
			 necessary, treatment may include, contact lenses (for keratoconus, aphakia,
			 high magnification difference between lenses), when requested in writing and
			 prior authorized by Medicaid.
(2)
			 Orthoptics (eye exercises) must be prior authorized by Medicaid. Full
			 information justifying medical necessity (including number of sessions
			 anticipated) must be sent in writing to Medicaid before this service is
			 begun.
(3) Eyeglass lens changes,
			 within lens specifications authorized by Medicaid, may be supplied when needed
			 because of visual changes due to eye disease, surgery, or injury.
Author:
Jacquelyn King, Program Manager; Medical
				  Support
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. Part 401, et seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-17 - EYE CARE SERVICES › Section 560-X-17-.03 - Optometrist Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Services That May be Provided Other Than Correction of Refractive Error.
(a) In the conduct of an optometric eye
			 examination, if the optometrist suspects or detects abnormalities or
			 irregularities requiring medical treatment the case will be referred to an
			 appropriate doctor of medicine or osteopathy.
(b) If medically necessary, contact lenses
			 (for keratoconus, aphakia, high magnification difference between lenses), may
			 be provided when prior authorized by Medicaid.
(c) Orthoptics (eye exercises) must be prior
			 authorized by Medicaid. Full information justifying medical necessity
			 (including number of sessions anticipated) must be sent in writing to Medicaid
			 before this service is begun.
(d)
			 Eyeglass lens changes, within lens specifications authorized by Medicaid, may
			 be supplied when needed because of visual changes due to eye disease, surgery,
			 or injury.
(e) Photochromatic
			 lenses and UV400 coating may be prior authorized when justified in
			 writing.
(f) Post-operative
			 cataract patients may be referred by the ophthalmologist, with the patient's
			 consent, to an optometrist for follow-up care as permitted by state law. Any
			 subsequent abnormal or unusual conditions diagnosed during follow-up care shall
			 be referred back to the ophthalmologist. When submitting claims the appropriate
			 modifier identifying post-operative management must be utilized. If the
			 ophthalmologist receives payment for the global amount the post-operative claim
			 will deny. No post-operative management claim will be processed until referring
			 ophthalmologist has received payment for surgery. It shall be the
			 responsibility of the optometrist to confer with the ophthalmologist for
			 appropriate claim corrections and/or submissions.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-17 - EYE CARE SERVICES › Section 560-X-17-.04 - Eyeglasses

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Authorization
(a) Recipients under 21 years of age are
			 authorized two pair of glasses each year if indicated by an examination; a
			 prior authorization will be required for subsequent pairs requested in a
			 calendar year. Recipients 21 years of age and older are authorized one pair of
			 eyeglasses every two calendar years if indicated by an examination; a prior
			 authorization will be required for subsequent pairs requested within two
			 calendar years. These limitations also apply to fittings and
			 adjustments.
(b) Additional
			 eyeglasses which are medically necessary may be prior authorized by Medicaid
			 for treatment of eye injury, disease or significant prescription
			 change.
(c) The provider should
			 forward a letter to Medicaid justifying medical necessity prior to ordering the
			 eyeglasses (reference Rule No.
			 560-X-17-.01(3).
(d) A response of either approval or denial
			 will be returned to the provider. If approved, a prior authorization number
			 will be assigned (reference Rule No.
			 560-X-17-.01(3)
(e) If a patient desires frames or
			 lenses other than those covered by Medicaid he/she must pay the complete cost
			 of the eyeglasses, including fitting and adjusting; Medicaid will not pay any
			 part of the charge. To prevent possible later misunderstanding, the provider
			 should have the patient sign the following statement for retention with the
			 patient's records: "I hereby certify that I have been offered Medicaid
			 eyeglasses but prefer to purchase the eyeglasses myself."
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-17 - EYE CARE SERVICES › Section 560-X-17-.05 - Billing Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All
			 claims for payment of services rendered, filed by ophthalmologists,
			 optometrists, and opticians are to be billed on appropriate form provided by
			 the fiscal agent.
(2) Claims are to
			 be forwarded directly to the Medicaid fiscal agent for payment within one year
			 of the date of service. The Medicaid Provider Manual contains information on
			 claims processing.
(3) A claim for
			 payment may be submitted for a cancelled order.
(4) Eye Examination Only.
(a) The claim should specify "Complete Eye
			 Examinations and Refraction."
(b)
			 If services other than a "complete examination" are provided, the claim should
			 reflect the appropriate optometric procedure code. This claim should be sent
			 directly to the Medicaid fiscal agent. This claim should be sent directly to
			 the Medicaid fiscal agent.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-17 - EYE CARE SERVICES › Section 560-X-17-.06 - Professional Fees (REPEALED)

Current through Register Vol. 42, No. 9, June 28, 2024
(REPEALED)
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-17 - EYE CARE SERVICES › Section 560-X-17-.07 - Special Situations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Eye
			 Care for Patients Eligible for Both Medicare and Medicaid. See the Medicaid
			 Provider Manual for instructions in filing claims when the Medicaid patient is
			 entitled to benefits covered by Medicare.
(2) If eyeglasses are prescribed under
			 conditions not covered by Medicare, instructions and procedures appearing in
			 other paragraphs of this chapter should be followed.
(3) Unusual Situations.
(a) Services for unusual situations may be
			 provided when prior authorized. Full, written information justifying medical
			 necessity must be sent to Medicaid prior to the service being
			 rendered.
(b) Please refer to Rule
			 560-X-17-.01(3)
			 for prior authorization procedures.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-17 - EYE CARE SERVICES › Section 560-X-17-.08 - Assuring High Quality Care

Current through Register Vol. 42, No. 9, June 28, 2024
Under the provisions of federal and state law. Medicaid must
				establish a mechanism to ensure that all care is of good quality and that the
				service(s) for which billing was made, conforms to that which was done. See
				Rule 560-X-2-.01(1)
				for criteria.
Author:
Jacquelyn King, Program Manager; Medical
				  Support
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. S401,
et seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-17 - EYE CARE SERVICES › Section 560-X-17-.09 - Co-Payment (Cost-Sharing)

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Ophthalmologists and optometrists are required to collect and it is the
			 Medicaid recipient's responsibility to pay the designated co-payment amount for
			 each service rendered. This requirement includes patients with
			 Medicare.
(2) Exceptions to the
			 copayment requirement are listed in Rule
			 560-X-1-.25.
(3) A provider may not deny services to any
			 eligible individual on account of the individual's inability to pay the
			 co-payment amount.
Author:
Jacquelyn King, Program Manager; Medical
				  Support
Statutory Authority:
State Plan, Attachment
				  4.18-A; 42 C.F.R.
				  §§
											447.55.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.01 - Transportation Services - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Title XIX (Medicaid) Plan for Alabama
			 provides for transportation of eligible recipients to and from sources of
			 medical care. Service will be provided either as a benefit or as an
			 administrative expense through methods ranging from voluntary no-cost to paid
			 ambulance transportation.
(2) The
			 approved plan includes:
(a) Reimbursement of
			 ambulance service for emergency and nonemergency situations without prior
			 approval and special situations with preauthorization given by Alabama Medicaid
			 Agency; and
(b) Coordination with
			 the Department of Human Resources to conduct a program within the counties to
			 arrange for transportation from existing recognized nonprofit volunteer groups.
R. Dale Boyles
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.02 - Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Recipient - An
			 individual determined to be eligible for Medicaid under the state
			 plan.
(2) Ambulance.
(a) Vehicle specifically designed and
			 equipped for transporting the wounded, injured, ill, or sick. Medicaid
			 recognizes three levels of ambulance services: Basic Life Support (BLS),
			 Advanced Life Support (ALS), and Non-emergency Ambulance Transportation. For a
			 concise definition of these ambulance services refer to the Ambulance (Ground
			 & Air) and/or Non-emergency Transportation (NET) Program chapters of the
			 Alabama Medicaid Provider Manual.
(b) All ambulances licensed and operating in
			 Alabama shall have the essential equipment on board as listed in Rule No.
			 420-2-1-.04, Ambulance Vehicle
			 Specifications; Emergency Medical Services Rules; Alabama Department of Public
			 Health. Effective date of this publication is January 1991.
(c) Exceptions: The above referred rules,
			 regulations, and standards shall not apply to:
1. Volunteer rescue squads that are members
			 of Alabama Association of Rescue Squads.
2. Ambulances operated by federal
			 agencies.
3. Ambulances which are
			 rendering assistance to licensed ambulances in the case of an emergency in
			 which the licensed ambulances of Alabama are insufficient or unable to provide
			 necessary ambulance services.
4.
			 Ambulances which are operated from a location or headquarters outside Alabama
			 that transport patients from outside the state to locations within the
			 state.
(d) No
			 out-of-state ambulance shall be used to pick up patients for transportation
			 point-to-point within Alabama unless the ambulance operator and ambulance
			 attendant hold current Alabama licenses.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.03 - Prior Authorization

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All
			 non-emergency ambulance service rendered to eligible Alabama Medicaid
			 recipients 100 miles or more one way where medical care is received), requires
			 prior authorization.
(2) All
			 requests for prior authorization by the attending physicians or their
			 representatives will be directed to the Medicaid's Fiscal Agent.
Author:
Carol Akin, Associate Director,
				  Clinic/Ancillary Services
Statutory Authority:
State Plan; 42 C.F.R.
				  §§401
et seq
.; Title XIX, Social Security
				  Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.04 - Scope Of Ambulance Transportation Service Operations

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All
			 transportation must be medically necessary and reasonable. Documentation must
			 state the condition(s) that show necessity of ambulance service, (and indicate
			 why patient could not be transported by another mode of
			 transportation).
(2) No payment may
			 be made for ambulance service if some other means of transportation could be
			 utilized without endangering the recipient's health.
(3) Emergency ambulance services are provided
			 to eligible recipients between:
(a) Scene
			 (address) of emergency and local hospital.
(b) Nursing home and local
			 hospital.
(c) Local hospital and
			 specialized hospital (Example: from Montgomery and University of Alabama
			 Hospital in Birmingham).
(d)
			 Exception: Ambulance service to a physician's office is not considered an
			 emergency.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.05 - Ambulance Service Participation

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All in-state and borderline out-of-state
			 providers (within a 30-mile radius of the state line), in compliance with Rule
			 No. 560-X-18-.02(2)(b)
			 above, will be afforded an opportunity to sign an ambulance service contract
			 with Alabama Medicaid Agency, to participate in the program for providing
			 ambulance service to Title XIX eligible recipients. Written enrollment requests
			 should be forwarded to Transportation Services, Alabama Medicaid Agency, 501
			 Dexter Avenue, Montgomery, Alabama 36104.
(2) The following items require that a new
			 Ambulance Service contract be entered into with the Alabama Medicaid Agency:
(a) Expiration of State License and new
			 license issued.
(b) Change of
			 ownership.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.06 - Payment For Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 transportation provider is responsible for completion of the HCFA 1500 claim
			 form. All claims submitted will be required to include the diagnosis code,
			 modifiers, and indicators as appropriate.
(2) Payment for ambulance services shall be
			 based on the lesser of the submitted charge or Alabama Medicaid's statewide
			 ambulance service rate. These payments shall not exceed combined payments for
			 providing comparable services under comparable circumstances under Medicare
			 and/or more than the prevailing charges in the locality for comparable services
			 under comparable circumstances.
(3)
			 Air transportation for adults 21 years of age and older will be reimbursed at
			 the emergency ground rate.
(4)
			 Ambulance services billed will be commensurate with services actually
			 performed. Services rendered are independent of the type of call received or
			 the type staff/equipped ambulance service responding.
(5) An Alabama Medicaid Provider may bill an
			 Alabama Medicaid recipient when the recipient has exhausted all of his/her
			 allowed Medicaid benefits for the calendar year, or when the service rendered
			 by the provider is a non-covered benefit as outlined in the Alabama Medicaid
			 Agency Administrative Code.
Author:
Ginger Collum, Program Manager,
				Clinic/Ancillary Services
Statutory Authority:
State Plan; 42 C.F.R.
				  §§401,
et
seq
.;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.07 - Time Limitation For Filing Medicaid Claims

Current through Register Vol. 42, No. 9, June 28, 2024
Claims for payment (appropriate forms provided by fiscal agent
				for Medicaid) from provider of service shall be submitted to fiscal agent for
				Medicaid within one year of the date of service.
Authors:
Charles A. Reasner, James V. Harris, R.
				Dale Boyles.
Statutory Authority:
State Plan; 42 C.F.R.
				  §§401
et
.
seq
.;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.08 - Third Party Responsibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Please refer to Chapter No. 560-X-20,
			 Third Party, for information concerning filing insurance and release of
			 information pertaining to recipients' changes.
R. Dale Boyles
Statutory Authority:
State Plan; 42 C.F.R.
				  §§401
et
seq
.;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.09 - Individuals Eligible For Both Medicare And Medicaid

Current through Register Vol. 42, No. 9, June 28, 2024
(1) An individual who is either sixty-five
			 (65) years of age or older, who is under sixty-five (65) years of age, and who
			 has been receiving green Social Security disability checks for twenty-four (24)
			 consecutive months, who presents a current white Medicaid Eligibility Card
			 without a Medicare Claim Number should be questioned about coverage under
			 Medicare.
(2) If the recipient does
			 not have a Medicare card and if he/she has not applied for Medicare, he/she
			 should be advised to contact the District Social Security Office
			 immediately.
(3) Claims should not
			 be filed with Medicaid until the Social Security Office makes a determination
			 about eligibility for Medicare.
(4)
			 Please refer to Chapter 1, General.
Authors:
Sheila G. Dunbar, R. Dale
				Boyles
Statutory Authority:
State Plan; 42 C.F.R.
				  §§401
et
seq
.;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.10 - Volunteer Services

Current through Register Vol. 42, No. 9, June 28, 2024
Alabama Medicaid Agency and the Department of Human Resources
				(county level) shall work for procurement of additional volunteer
				transportation support from volunteer groups and nonprofit
				organizations.
R. Dale Boyles
Statutory Authority:
State Plan; 42 C.F.R.
				  §§401
et
seq
.;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.11 - Out-Of-State Transportation

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 All written or verbal communications pertaining to Alabama Medicaid recipients
			 from out-of-state physicians or providers of ambulance transportation, will be
			 referred to Alabama Medicaid Agency, 501 Dexter Avenue, Montgomery, Alabama
			 36104.
(2) Appropriate billing
			 forms will be provided at a fee to ambulance service providers upon
			 request.
(3) Payment will be as
			 stated in Rule No. 560-X-18.07.
(4)
			 Processing for payment will be the same as Rule No.
			 560-X-18-.13(6) and
			 (8).
(5) All out-of-state providers of ambulance
			 service are responsible for compliance with all applicable paragraphs of this
			 Alabama Medicaid Regulations Manual, when requesting payment for service
			 provided an eligible Alabama Medicaid recipient.
R. Dale Boyles
Statutory Authority:
State Plan; 42 C.F.R.
				  §§401
et
seq
.;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.12 - Providers Of Service Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
(1) To be eligible for participation in the
			 Alabama Medicaid Ambulance Program and to receive payment for service, each
			 provider of ambulance service in Alabama in compliance with Rule No.
			 560-X-18-.02(2)
			 must enter into a written agreement with Alabama Medicaid Agency.
(2) Ambulance Service Agreement (contract)
			 available from the Alabama Medicaid Agency, must be completed in two (2)
			 copies.
(3) Contract must be
			 approved by Alabama Medicaid Agency with an effective date for payment of
			 Medicaid covered ambulance services. The effective date of the contract will be
			 the first day of the month the Agency signs the contract.
(4) The Ambulance Service Agreement
			 (contract) may be terminated for failure of the parties to fulfill one or more
			 of the contract provisions. Medicaid reserves the right to immediately
			 terminate a contract in the event of fraud or a criminal conviction.
(5) Each party may terminate the agreement on
			 thirty (30) days written notice.
(6) The permanent record copy which fully
			 discloses the extent and cost of services, equipment, or supplies furnished
			 eligible recipients must be maintained by the provider and available for audit
			 by State and Federal auditors for a period of three (3) years.
(7) Providers of transportation are
			 responsible for verifying the recipient's current Medicaid
			 eligibility.
(8) All required
			 blanks and spaces on the claim form must be completed before submitting it to
			 the Medicaid fiscal agent for payment.
Author:
Statutory Authority:
State Plan; 42 C.F.R.
				  §§401
et
seq
.;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.13 - Providers Of Ambulance Service Responsibilities

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Act No. 645 passed by the 1976 Regular
			 Session of the Legislature of Alabama provided that any person who, with intent
			 to defraud or deceive, makes or causes to be made, any false statement or
			 representation of material fact in any claim or application for any payment,
			 regardless of the amount from Alabama Medicaid Agency, knowing the same to be
			 false, shall be guilty of a felony.
(2) All services will be provided without
			 discrimination of race, color, or national origin, as in accordance with the
			 provisions of Title VI of the Civil Rights Act of 1964, and Section 504 of the
			 Rehabilitation Act of 1973.
(3) The
			 provider of Ambulance Services, will assume all responsibility for operation of
			 the service if a medical/legal accident should occur.
Authors:
James V. Harris, R. Dale
				Boyles.
Statutory Authority:
State Plan; 42 C.F.R.
				  §§401
et
seq
.;
				  Title XIX, Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.14 - Assuring High Quality Care

Current through Register Vol. 42, No. 9, June 28, 2024
Under the provisions of Federal and State law, Medicaid must
				establish a mechanism to ensure that all such care is of good quality and that
				the service(s) for which billing was made, conforms to that which was done. See
				Chapter 2, Rule
				560-X-2-.01(2) and
				(3) for criteria.
R. Dale Boyles
Statutory Authority:
State Plan; 42 C.F.R.
				  §401
et
seq
.; Title XIX,
				  Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.15 - Air Transportation Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Covered Services
(a) Air transportation services are covered
			 for adults and children with authorization required prior to payment. Air
			 transportation may be rendered only when basic and advanced life support land
			 ambulance services are not appropriate. Medical appropriateness may be
			 established when the time of need to transport by land or the instability,
			 inaccessibility, or other obstacles to land transportation poses a threat to
			 survival or seriously endangers the recipient's health. In certain cases when
			 time required to transport by land as opposed to air endangers the recipient's
			 life or health, services may be authorized. Air transportation will not be
			 provided for convenience.
(b)
			 Medicaid requires that the patient is taken to the nearest hospital having
			 appropriate facilities, physicians, or physician specialist needed to treat the
			 patient's condition. The hospital must also have a bed or specialized treatment
			 unit immediately available. If the patient is not taken to the nearest
			 appropriate hospital, payment will be limited to the rate for the distance from
			 the pick up point to the nearest appropriate hospital.
(c) If it is determined that land ambulance
			 service would have been more appropriate, payment for air transportation will
			 be based on the amount payable for land transportation. Trips less than 75
			 loaded air miles are not considered to be appropriate unless extreme,
			 extenuating circumstances are present and documented.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.16 - Non-Emergency Transportation Program General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) As the State Agency for administering the
			 Non-Emergency Transportation Program, under Title XIX of the Social Security
			 Act, the Alabama Medicaid Agency must ensure that transportation for Medicaid
			 allowable medical services is available for all eligible recipients in the
			 state who have no other means of transportation.
(2) Medical transportation services include
			 transportation of a Medicaid recipient to and from Medicaid allowable medical
			 services for which a recipient has available benefits.
(3) In order to eliminate or reduce
			 transportation barriers for Medicaid recipients, Medicaid created the
			 Non-Emergency Transportation Program (NET). NET is responsible for ensuring
			 that necessary non-ambulance transportation services are provided in a manner
			 that is:
(a) similar in scope and duration
			 state-wide, although there will be some variation depending on resources that
			 are available in a particular geographical location of the state;
(b) consistent with the best interest of
			 recipients;
(c) appropriate to
			 available services, geographic location and limitations of
			 recipients;
(d) prompt;
(e) cost-effective, and
(f) efficient.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-18 - TRANSPORTATION SERVICES › Section 560-X-18-.17 - NET Trip Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Eligible recipients must receive the least expensive appropriate transportation
			 that does not endanger their health, to facilities that are accessible and
			 appropriate for Medicaid covered medical services for which a recipient has
			 available benefits.
(2) Recipients
			 who request out-of-state transportation to medical facilities must have a
			 physician submit to the Alabama Medicaid Agency a physician's statement which
			 justifies the need for medical services out-of-state and that such services
			 cannot be obtained in-state.
Author:
Dorothy Powell, Associate Director,
				  Non-Emergency Transportation Program
Statutory Authority:
State Plan;
				  42 C.F.R. §
											431.53; Title XIX, Social Security
				  Act.