Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.20 - Hospital Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Covered Services - Reasonable and necessary hospital care medical services for
			 an occupational illness or injury including acute-care hospital inpatient,
			 outpatient, and rehabilitation facilities, shall be reimbursable as stated in
			 Rule 480-5-5-.04(3),
			 if the services rendered are related to the compensable illness or injury and
			 are ordered and certified by the attending physician.
(2) Reimbursement - If the claimant is
			 receiving treatment for both compensable and noncompensable medical conditions,
			 only those services provided in treatment of compensable conditions shall be
			 listed on claim forms submitted to the adjudicator unless the noncompensable
			 condition has a direct bearing on the treatment of the compensable condition.
			 In addition, payments from private payors for noncompensable conditions shall
			 not be listed on claim forms submitted to the employer/agent.
(a) The statement of charges shall be made in
			 accordance with standard coding methodology as described in Rule
			 480-5-5-.04.
(b) When requested, the facility shall submit
			 a copy of the outpatient charge master to the Department of Industrial
			 Relations Workers' Compensation Division for the Ombudsman Program, or an
			 itemized listing of the individual items and services that contribute to the
			 outpatient charges.
(c) Inpatient
			 reimbursement shall be limited to the prevailing reimbursement as described in
			 Rule 480-5-5-.04(3)
			 for participating and nonparticipating hospitals or limited to the lesser
			 negotiated rates for privately contracted hospitals pursuant to
Code of Ala. 1975
, §25-2-314. The formula for
			 calculating a per diem payment amount shall be "Per Diem Rate x Inpatient Days
			 = Per Diem Amount." Any variations form a pure per diem payment methodology
			 shall be controlled by the language of the agreement or statutory committee
			 statement.
(d) Outpatient
			 reimbursement shall be covered charges minus the applicable outpatient discount
			 percentage (O.P.%) as stated in any participating hospital agreement or any
			 nonparticipating hospital committee statement for reimbursement. The formula
			 for calculating payment amount shall be "Billed Charges - Noncovered Charges =
			 Covered Charges x O.P.% = Discount Amount. Covered Charges Discount Amount =
			 Payment Amount."
(e) Professional
			 medical services rendered on an outpatient basis by providers such as medical
			 doctors, physical therapists, occupational therapists, speech therapists, or
			 other providers as allowed pursuant to these rules and each provider's practice
			 act, shall be reimbursed based on the appropriate provider's Maximum Fee
			 Schedule. Any facility fees associated with delivery of these professional
			 medical services shall be reimbursed at covered charges minus the outpatient
			 percentage discounted amount. The formula for calculating payment is specified
			 in (2)(d) of this Rule 480-5-5.20.
Author:
Workers' Compensation
				Division