reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.08 - Recipient Rights And Responsibilities

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Free choice of selecting providers of
			 health care is a legal right of every recipient of Medicaid care and services.
			 Freedom of choice related to an individual' sopport unity to make his/her own
			 decisions for his/her own reasons, free from the arbitrary authority of others,
			 is a recipient's right.
(2) Where
			 prior authorization is required for Medicaid services, a recipient's choice
			 among qualified providers shall not be restricted except by special action of
			 the Alabama Medicaid Agency to restrict or "lock-in" a recipient to a provider
			 of choice. (See Chapters 4 and 5 for additional information on recipient
			 restrictions.)
(3) A recipient who
			 believes that his/her free choice of provider has been denied or impaired has
			 the right to request a fair hearing before the Alabama Medicaid
			 Agency.
(4) When a recipient fails
			 to advise a provider of his/her Medicaid eligibility and furnish other
			 information necessary to file the claim within the time allowed by Medicaid,
			 the provider is under no obligation to file and may elect to file with Medicaid
			 or to bill the patient.
Author:
Kathy Hall, Deputy Commissioner, Program
				  Administration
Statutory Authority:
Social Security Act, Title
				  XIX; 42 C.F.R. §§
											431.51,
				  431.54.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.09 - Recipient Identification Number

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The identification number of Medicaid
			 eligible recipients contains 13 digits. The first three will be "500" or
			 "530".
(2) The Medicaid
			 identification number will be embossed on a plastic Medicaid eligibility card
			 issued to each individual entitled to Medicaid.
(3) Providers should question patients aged
			 65 or older about entitlement to Medicare.
(a) Where a Medicare claim number has not
			 been assigned for those aged 65 or older, the recipient should be referred to
			 the local SSA office to make application for Medicare.
(b) Claims for services covered by Medicare
			 may not be submitted until a Medicare number has been assigned; then claim
			 should be filed first with Medicare with the Medicaid number listed on the
			 Medicare claim as "other insurance."
(c) A Medicare claim number with a suffix "M"
			 indicates there is no Medicare Part A (hospital insurance) entitlement.
			 Hospital claims for this type number may be filed with Medicaid as regular
			 Medicaid claims.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.10 - Provider Identification Number

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All providers participating in the
			 Alabama Medicaid Program are assigned an identification number by the Alabama
			 Medicaid Agency fiscal agent.
(2)
			 Providers must be licensed to practice in the state in which the service is
			 rendered.
(3) Providers must have a
			 National Provider Identifier (NPI).
Author:
Kathy Hall, Deputy Commissioner, Program
				  Administration
Statutory Authority:
State Plan for Medical
				  Assistance and the Alabama Medicaid Agency Administrative Code.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.11 - Medicaid Eligibility Card

Current through Register Vol. 42, No. 9, June 28, 2024
Individuals certified eligible for Medicaid will receive a
				plastic Medicaid Card through the mail with the following exceptions: certain
				unborns; recipients certified with a pseudo number; Medicare Savings Programs
				other than "QMB; and recipients certified for a closed period of retroactive
				eligibility. These individuals will receive a paper Medicaid card. Also,
				Medicaid recipients residing in a long term care facility will not receive a
				plastic Medicaid card. Each month the long term care provider will receive a
				computer printout listing of all Medicaid eligible recipients in the respective
				facility.
(1) The recipient is
			 required to present his plastic Medicaid card and proper identification to a
			 provider of medical care or services. The provider must verify eligibility
			 through web portal, AVRS, MACSAS, or the Provider Inquiry Unit.
(2) Medicaid claims may be submitted for
			 incurred charges during three months prior to the month of application.
			 Eligibility must be established before claims submission may be paid.
(3) When a recipient loses or fails to
			 receive a plastic eligibility card he/she should write or call the Alabama
			 Medicaid Agency.
(a) Should the recipient
			 require Medicaid services before receiving a replacement card he/she is
			 responsible for furnishing his/her Medicaid number to the provider at a later
			 time.
(b) Providers of Medicaid
			 services shall obtain the Medicaid eligibility number directly from the
			 recipient to verify eligibility or submit claims for services furnished the
			 recipient. Where the Medicaid number is not available from the recipient, it
			 may be obtained from the Medicaid Agency by sending a completed inquiry form.
			 Providers must state in their request that they have provided authorized
			 services, supplies, or equipment to the individual whose Medicaid number is
			 being verified.
(c) Claims
			 submitted for services furnished a recipient must contain all 13 digits of the
			 recipient's Medicaid number.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.12 - Medicaid Eligibility Termination

Current through Register Vol. 42, No. 9, June 28, 2024
(1) When a recipient is notified by the
			 Social Security Administration that he/she is no longer eligible for
			 Supplemental Security Income, Medicaid will send a termination notice unless
			 he/she remains eligible for Medicaid under Alabama criteria. A recipient shall
			 be notified at least ten days before the effective date of termination from
			 Medicaid benefits. Chapter 28 provides two types of termination
			 notices.
(2) In all other
			 termination's Medicaid and the Department of Human Resources issue Termination
			 Notices ending Medicaid eligibility.
(3) Medicaid recipients residing in an
			 institution may lose eligibility if they are discharged from the institution to
			 home, or if their monthly income or resources rise above the limit for Medicaid
			 eligibility.
(4) If a Medicaid
			 eligible person, other than a foster child, moves permanently outside the State
			 of Alabama, he/she will be terminated from Alabama Medicaid.
(5) Foster children will lose eligibility
			 when they cease to be foster children.
(6) Minors eligible for Early and Periodic
			 Screening, Diagnosis and Treatment (hereinafter called EPSDT) will lose
			 eligibility age 21.
(7) Medicaid
			 recipients will lose eligibility when income exceeds the limit established for
			 eligibility.
Author:
Kathy Hall, Deputy Commissioner, Program
				  Administration
Statutory Authority:
State Plan; 42 C.F.R.
				  §§430,
et
seq
.;Social Security Act, Title
				  XIX.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.13 - Medicaid Payments And Recoupments For Health Services, Supplies, And Equipment

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Direct payments are made for allowable charges to providers for covered medical
			 services and supplies furnished eligible Medicaid recipients.
Providers who wish to participate in the Alabama Medicaid
				Program must be enrolled, receive a provider number, and sign a contract with
				Medicaid.
(2) Crossover
			 payments are partial payments to providers by Medicaid for covered Medicaid
			 services, supplies and equipment furnished to recipients eligible for both
			 Medicare and Medicaid.
(a) For Medicare
			 covered services, providers of services, supplies, and equipment to eligible
			 Medicare/Medicaid recipients must submit their claims primary to Medicare and
			 not to the Medicaid fiscal agent.
(b) Claims paid by the Medicare contracted
			 intermediary will be electronically forwarded to the Medicaid fiscal agent for
			 payment to the provider of the deductible and coinsurance charges. This is the
			 "crossover" payment and will be listed on the provider's Medicaid Remittance
			 Advice (RA). Claims denied by the Medicare intermediary are not forwarded to
			 the Medicaid fiscal agent.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.14 - Medicaid Payments For Medicare/Medicaid And/Or Qualified Medicare Beneficiaries (QMB) Eligible Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
Medicaid pays the monthly premiums for Medicare insurance for
				an eligible Medicare/Medicaid and/or QMB recipient to the Social Security
				Administration. Medicaid also pays the applicable Medicare Part A and Part B
				deductibles and/or coinsurance for an eligible Medicare/Medicaid and/or QMB
				recipient, as specified below.
(1)
			 Definitions
(a) "QMB" recipient is a Part A
			 Medicare beneficiary whose verified income and resources do not exceed certain
			 levels.
(b) "Deductible" is the
			 dollar amount a Medicare eligible must pay for his/her own health care
			 services.
(c) "Coinsurance" is the
			 percentage of each bill a Medicare eligible must pay under certain conditions,
			 in addition to the deductible amount.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.15 - Out-of-state Care And Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Medical care and services provided
			 outside the State of Alabama for Alabama Medicaid recipients are covered
			 services if and only if such services are covered when rendered in-state and
			 are medically necessary.
(a) Medical care and
			 services which require prior authorization for in-state providers will continue
			 to require prior authorization for out-of-state providers.
(b) Out of state providers must follow the
			 enrollment procedures of the Alabama Medicaid Agency.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.16 - In-State Care And Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) For each of the several categories of
			 Medicaid covered services there may be state imposed limitations on frequency,
			 amount, type, or kinds of services for which Medicaid will pay. Additional
			 information concerning covered services limitation is found in the program
			 chapters of this Code.
(2)
			 Limitations of Medicaid services and supplies may not be absolute. In
			 individual cases of justified medical necessity they may be exceeded if prior
			 approval is obtained from Medicaid. Chapters concerned with covered services
			 explain how to obtain prior approval for services beyond the state's normal
			 limit.
Author:
Statutory Authority:
State Plan, Attachment
				  3.1-A; 42 C.F.R.
				  §§
											440.210,
				  441.10; Social Security Act, Title
				  XIX, §1902 (a) (10) (A).
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.17 - Providers' Claims

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Providers
			 of services and supplies shall submit claims electronically.
(2) Instructions concerning claim forms
			 completion and processing procedures are contained in the provider manual(s)
			 posted to the Alabama Medicaid website.
(3) Time limits for Claim Submission.
(a) Medicaid will pay only clean claims
			 submitted timely to its fiscal agent. A clean claim is a claim which can be
			 processed for payment or denied without obtaining additional information from
			 the provider. A timely claim is a clean claim which is received by the fiscal
			 agent within one year of the date of service, unless a different limitation is
			 specifically provided elsewhere in this Code.
(b) A claim which does not have sufficient
			 information to be entered into the automated claims processing system will be
			 returned to the provider (RTP) and will not be considered as a clean claim
			 submitted timely to the fiscal agent.
(c) A clean claim which is not timely
			 received by the fiscal agent will be denied as outdated, except as provided in
			 paragraph (4) below.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.19 - Sales Tax On Medicaid Paid Items

Current through Register Vol. 42, No. 9, June 28, 2024
(1) State and municipal gross sales taxes
			 within Alabama are not to be included in charges for Medicaid covered services,
			 medical supplies and equipment.
(2)
			 Alabama law exempts from any state gross sales taxes all medicines prescribed
			 by physicians when the prescription is filled by a licensed pharmacist or sold
			 to the patient by the physician for human consumption or intake.
Author:
Statutory Authority:
Code of Ala.
				  1975
, §
										40-23-4.1.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.20 - Consent For Health Services For Certain Minors And Others

Current through Register Vol. 42, No. 9, June 28, 2024
Consent for health services for certain minors, and others,
				will be governed by
Code of Ala. 1975
, Title 22,
				Chapter 8.
Author:
Statutory Authority:
Code of Ala.
				  1975
, §§
										22-8-1,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.21 - Provider Medicaid Records Inspection/Audit

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Alabama Medicaid providers shall keep
			 detailed records in Alabama, except as provided in subparagraph (5), Rule
			 560-X-16-.02, that will fully
			 disclose the extent and cost of services, equipment, or supplies furnished
			 eligible recipients. These records will be retained for a period of three years
			 plus the current year.
(2) All
			 orders must be written according to practice guidelines and state/federal law
			 and must include the date and signature of the provider, the service(s) ordered
			 and the recipient's name. Refer to the individual provider manual chapters for
			 detailed description of what must be included in an order.
(3) Providers shall make all such records
			 available for inspection and audit by authorized representatives of Secretary
			 of Health and Human Services, Alabama Medicaid Agency and other agencies of the
			 State of Alabama. Provider records and operating facilities shall be made
			 available for inspection during normal business hours.
(4) All providers shall, upon either verbal
			 or written request from any agencies listed above, furnish free of charge a
			 copy of any requested record. If the provider has no copies, the provider must
			 allow the person requesting the copy to check out the original for copying. The
			 provider may require that a receipt be given for any original record removed
			 from his premises. If the provider does not furnish records when requested, the
			 Agency may seek a recoupment of payment(s).
(5) When records are requested, providers
			 must send all associated documentation that supports the services billed within
			 the timeframe designated in the verbal or written request. Sometimes that
			 information may come from a visit or test performed earlier than the timeframe
			 of the review. Elements of a complete medical record may include but are not
			 limited to:
(a) Physician orders and/or
			 certifications of medical necessity
(b) Patient questionnaires associated with
			 physician services
(c) Progress
			 notes of another provider that are referenced in your own note
(d) Treatment logs
(e) Related professional consultation
			 reports
(f) Procedure, lab, x-ray
			 and diagnostic reports
(g) Billing
			 provider notes to support the billed date of service
(h) Delivery logs/tickets
(i) Itemized statements/invoices
(j) Prescriptions
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.22 - Declaration Of Emergency Plan Of Action To Protect Public Health And Welfare

Current through Register Vol. 42, No. 9, June 28, 2024
(1) When the
			 State of Alabama is under a state of emergency proclamation, it may be
			 necessary, in order to protect the public health and welfare of the citizens of
			 Alabama, for the Medicaid Agency to implement procedures that will contradict,
			 and therefore supersede, promulgated rules utilizing the Alabama Medicaid
			 Agency provider ALERT system.
(2)
			 The Provider ALERT must state the affected rule and have an explanation as to
			 why it is superseding the rule. It must specifically relate the reason to the
			 emergency proclamation and must have an end date not to exceed 60 days, unless
			 ended earlier by the termination of the state of emergency.
(3) Any ALERT issued pursuant to this rule
			 shall control regarding the specific service(s) described in said ALERT. The
			 extension of the state of emergency proclamation does not serve to extend any
			 ALERT issued under this rule and the Commissioner of Medicaid shall have
			 discretion to end any ALERT issued under this rule at any time before the state
			 of emergency ends.
(4) The intent
			 of this rule is to allow the Medicaid Agency to lessen the restrictions placed
			 upon Medicaid providers when it is necessary to protect the public health and
			 welfare of the citizens of Alabama. This rule shall not be utilized to increase
			 restrictions placed upon Medicaid providers by this Administrative
			 Code.
Author:
Stephanie Lindsey, Administrator,
				  Administrative Procedures Office
Statutory Authority:
Code of Ala.
				  1975
, §
										41-22-1 et.
				  seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.23 - Payments

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All payments
			 shall be subject to the availability of appropriated funds for the Alabama
			 Medicaid Program.
(2)
			 Notwithstanding anything in this code to the contrary, in the event of
			 proration of state funds available to the Alabama Medicaid Program, payment for
			 Medicaid benefits shallbe made in accordance with provisions of the Alabama
			 State Plan for Medical Assistance.
Author:
Statutory Authority:
State Plan;
Code of Ala. 1975
, §
										41-4-90.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.24 - Limitations On Providers

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 Alabama Medicaid Agency will normally enroll providers of covered services and
			 issue provider contracts to new provider applicants who meet the requirements
			 of the Code of Federal Regulations, the licensure and/or certification
			 requirements of the State of Alabama, and the Administrative Code and operating
			 procedures of the Alabama Medicaid Agency.
(2) Providers who have been convicted of
			 fraud will not be considered for contract with the Medicaid Agency.
(3) The Alabama Medicaid Agency may terminate
			 an existing contract of a provider when the Agency determines that during the
			 last fiscal year the provider has provided services to Medicaid-only recipients
			 not exceeding five claims and/or $100.00or, the provider has not submitted any
			 claims in the previous 18months.
Author:
Kathy Hall, Deputy Commissioner, Program
				  Administration
Statutory Authority:
Title XIX, Social Security
				  Act; 42 C.F.R.§§
											431.51,
				  440.230,
				  440.240,
				  442.10,
				  442.12(d)(1),
				  447.204,
et
seq
., 431.107, Part 455,
				  Subpart C, and Part 405.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.25 - Copayment (Cost-Sharing)

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medicaid recipients are required to pay the designated copayment amount for the
			 following services (including Medicare crossovers):
(a) Physician office visits (including
			 optometric)
(b) Inpatient hospital
			 admissions
(c) Outpatient hospital
			 visits
(d) Rural health clinic
			 visits
(e) Durable medical
			 equipment
(f) Medical
			 supplies
(g)
			 Pharmaceutical
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.26 - Ancillary Services Associated With Noncovered Benefits

Current through Register Vol. 42, No. 9, June 28, 2024
When a medical benefit is a noncovered service under the
				Alabama Medicaid Program, all ancillary charges related to delivery of that
				benefit are also considered non covered.
Author:
Harriette M. Worthington
Statutory Authority:
State Plan; Title XIX of
				  the Social Security Act; 42 C.F.R. §§401,
et
seq
.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.27 - Organ Transplants

Current through Register Vol. 42, No. 9, June 28, 2024
Alabama Medicaid will cover organ transplants under the
				following terms and conditions. These terms will apply to all procedures except
				cornea transplants.
(1) Transplants
			 must be performed in the state of Alabama if medically available and
			 appropriate for particular patient and transplant type with the exception of
			 (8)(d) below.
(2) All transplant
			 candidates must be from referrals by EPSDT or the primary physician.
(3) All transplant evaluations must be
			 conducted by the Medicaid primary contractor. If the primary contractor is
			 unable to perform the transplant, a referral to another facility may be made.
			 The primary contractor will be responsible for coordination and reimbursement
			 of referrals.
(4) The following
			 transplants are covered for recipients of any age:
(a) bone marrow,
(b) kidney,
(c) heart,
(d) lung,(single or double)
(e) heart/lung,
(f) liver,
(g) pancreas
(h) pancreas/kidney
(i) liver/small bowel
(j) small bowel
(k) liver/pancreas/small bowel
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.28 - Early And Periodic Screening, Diagnosis And Treatment

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Early and
			 Periodic Screening, Diagnosis, and Treatment (EPSDT) will be available for
			 Medicaid-eligible recipients under the age of 21 years old. This coverage will
			 be provided for medically necessary health care, diagnosis, treatment and/or
			 other measures described in §1905(a) of the Social Security Act and more
			 specifically in Chapter 11 of the
Alabama Medicaid Administrative
			 Code
.
(2) The services
			 must be necessary to correct or ameliorate a defect, physical or mental
			 illness, or other conditions discovered during or as a result of an EPSDT
			 screen,whether or not the services are covered or exceed benefit limits as
			 stated in the State Plan. Misspent funds identified as aresult of retrospective
			 review will be recouped in accordance with the procedures in Chapter 4 of the
Alabama Medicaid Administrative Code
.
Author:
Kathy Hall, Deputy Commissioner, Program
				  Administration
Statutory Authority:
State Plan, Attachment
				  3.1-A; Title IX,Social Security Act §1905; 42 C.F.R. 440, 441 ; OBRA-89
				  §6403.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.29 - Electronic Records And Signatures

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Medicaid may create, generate,
			 communicate, store, process, use, and rely upon electronic records and
			 signatures.
(2) Medicaid may
			 convert written records to electronic records.
(3) When converting written records to
			 electronic records, Medicaid will ensure the electronic records accurately
			 reflect the information set forth in the written records and remain accessible
			 in electronic form for all applicable record retention periods.
Author:
Gretel Felton, Deputy Commissioner,
				  Beneficiary Services
Statutory Authority:
Code of Ala.
				  1975
, §§
										8-1A-1, et seq.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-1 - GENERAL › Section 560-X-1-.30 - 340 B Entities

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 Veterans Health Care Act of 1992 enacted section 340 B of the Public Health
			 Services Act, "Limitation on Prices of Drugs Purchased by Covered Entities".
			 This Section provides that a manufacturer who sells covered outpatient drugs to
			 eligible 340B entities must sign a pharmaceutical pricing agreement with the
			 Secretary of Health and Human Services in which the manufacturer agrees to
			 charge to Medicaid a price for covered outpatient drugs that will not exceed
			 the average manufacturer price decreased by a rebate percentage.
(a) Eligible 340B entities are defined in
			 42 U.S.C. §
										256b(a) (4).
(b) When an eligible 340B entity, other than
			 a disproportionate share hospital, a children's hospital excluded from the
			 Medicare prospective payment system, a free-standing cancer hospital exempt
			 from the Medicare prospective payment system, sole community hospital, rural
			 referral center, or critical access hospital, submits a bill to the Medicaid
			 Agency for a drug purchased by or on behalf of a Medicaid recipient, the amount
			 billed shall not exceed the entity's actual acquisition cost for the drug, as
			 charged by the manufacturer at a price consistent with the Veterans Health Care
			 Act of 1992, plus the dispensing fee established by the Medicaid Agency. A
			 disproportionate share hospital, children's hospital excluded from the Medicare
			 prospective payment system, free-standing cancer hospital exempt from the
			 Medicare prospective payment system, sole community hospital, rural referral
			 center, or critical access hospital may bill Medicaid the total charges for the
			 drug. As manufacturer price changes occur, the entities must ensure that their
			 billings are updated accordingly.
(c) Eligible 340B entities are identified on
			 the Department of Health and Human Service's website. These entities shall
			 notify Medicaid of their designation as a 340B provider.
(d) Audits of the eligible 340B entities'
			 (claims submissions and invoices) will be conducted by the Medicaid Agency.
			 Eligible 340B entities, other than the providers listed above in paragraph (b),
			 must be able to verify acquisition costs through review of actual invoices for
			 the time frame specified. Charges to Medicaid in excess of the actual invoice
			 costs will be subject to recoupment by the Medicaid Agency in accordance with
			 Chapter 33 of the Administrative Code.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-2 - ASSURING HIGH QUALITY CARE › Section 560-X-2-.01 - Methods For Assuring High Quality Care

Current through Register Vol. 42, No. 9, June 28, 2024
The following methods shall be used in administering the
				Medical Assistance Program to ensure that medical remedial care, and service
				provided are of high quality, properly utilized and based on acceptable
				professional medical standards, state and federal laws and regulations.
(1) Peer Review Committees, as appropriate,
			 will be established in Alabama for the purpose of settling disputes related to
			 charges made for professional and other medical assistance services. Problems
			 submitted to Peer Review Committees may originate with Alabama Medicaid Agency,
			 its fiscal agent, providers, and recipients. Additional Peer Review Committees
			 may be established as needed.
(a) Problem
			 referral procedure.
1. The fiscal agent shall
			 gather information about a problem discovered through claims processing and
			 attempt to resolve it with a provider or recipient.
2. Where a solution cannot be reached, the
			 facts will be submitted to the Alabama Medicaid Agency for
			 resolution.
3. Problems not
			 resolved by the Alabama Medicaid Agency may be referred to the appropriate Peer
			 Review Committee. Medicaid will assemble the facts and arrange for the Peer
			 Review Committee to consider the problems at a mutually agreeable time and
			 place. When a professional specialty consultation is needed, Medicaid may
			 arrange for the service.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-3 - FAIR HEARINGS › Section 560-X-3-.01 - Fair Hearings-General

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 The State Plan provides that the office of the Governor acting through
			 Medicaid, will be responsible for fulfillment of hearing provisions for all
			 matters pertaining to the Medical Assistance Program under Title XIX. An
			 opportunity for a fair hearing shall be granted to any individual or provider
			 of services requesting a hearing because a claim for medical assistance or
			 payment for services provided a recipient is denied or is not acted upon with
			 reasonable promptness, or because the party is aggrieved by any other agency
			 action regarding receipt of medical assistance or payment for services, or by
			 an agency policy as it affects the situation, except as noted in paragraphs 3
			 and 4 below.
(2) The Hearing
			 Authority for all recipient and provider fair hearings for Alabama Medicaid
			 Agency is the Commissioner, who shall appoint one or more Hearing Officers, to
			 conduct fair hearings and submit findings and recommendations to the
			 Commissioner for final decision on each case. The Hearing Officer must not have
			 been involved in any way with the action in question.
(3) In general, eligibility for Medicaid is
			 based on eligibility for certain public assistance programs administered by the
			 Department of Pensions and Security, and the Social Security Administration.
			 Complaints concerning eligibility matters shall be referred to the appropriate
			 agency which made the eligibility determination for a hearing. Procedures shall
			 be set by the hearing agency.
(4)
			 Matters pertaining to hospital or nursing home decertification for
both
Title XVIII and XIX will be referred to the
			 Federal Health and Human Services Director for Health Standards and Quality in
			 Region IV. His office is responsible for making final decisions on
joint
program decertification.
Author:
John H. Ziegler
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-3 - FAIR HEARINGS › Section 560-X-3-.02 - Fair Hearings-Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A fair hearing is a face-to-face hearing
			 by an impartial State Hearing Officer at a time and place reasonably convenient
			 for the complainant and attended by the complainant or his authorized
			 representatives who may call witnesses or examine witnesses called by
			 others.
(2) A documentary hearing
			 is one in which all the evidence for both the complainant and the agency is
			 presented to the hearing officer in written form. He then makes his
			 recommendations based on the evidence presented. Recommendations and decisions
			 in documentary hearings have the same authority as those rendered in a
			 face-to-face hearing.
Authors:
Robert R. Crumpler; William O.
				Butler.
Statutory Authority:
§ 1902(a)(3), Title
				  XIX, Social Security Act;
				  42 C.F.R. §§
											431.200 -
				  431.245;
				  §
										41-22-12, Alabama Administrative
				  Procedure Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-3 - FAIR HEARINGS › Section 560-X-3-.03 - Fair Hearing Procedures For Recipients And Providers

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The procedures
			 contained herein have been adopted by Medicaid to settle formal complaints of
			 persons who are receiving care under the Medicaid program or who have been
			 denied care under this program because of eligibility standards, or for
			 providers who desire a fair hearing upon denial of a claim for services,
			 out-dated claim and non-renewal or termination of a contract. At the request of
			 a provider, the Commissioner may grant a fair hearing on any other matter
			 pertinent to Medicaid except the following:
a. When Medicaid suspends payments to a
			 provider after Medicaid determines there is a credible allegation of fraud,
			 pursuant to the requirements of
			 42 C.F.R. §
										455.23, the provider shall not be entitled to
			 a fair hearing regarding the suspension of payments;
b. When the Secretary of Health and Human
			 Services determines that a provider must be removed from the program for fraud
			 or abuse.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-3 - FAIR HEARINGS › Section 560-X-3-.04 - Fair Hearing Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A hearing shall be impartially conducted
			 and held at a time and place which is reasonably convenient for the parties,
			 and written notice of such time and place shall be given by the Director,
			 Hearings, or the designated Hearing Officer, at least ten (10) calendar days
			 before the hearing is to be held. This written notice will also contain
			 information explaining the complainant's rights and procedures regarding a
			 hearing.
(2) A complainant may be
			 represented or assisted by legal counsel at his own expense; he may have a
			 friend or relative present his case; or he may present his case
			 himself.
(3) A complainant or his
			 representative must attend his hearing unless he is given written permission by
			 appropriate authority to be absent. His failure to attend shall leave the
			 Hearing Officer with no alternative but to proceed with the hearing and render
			 a conclusion and recommendation in his absence based upon evidence presented by
			 the Alabama Medicaid Agency representatives.
(4) The complainant and/or his authorized
			 representative may call witnesses, and may examine witnesses called by others.
Author:
Robert R. Crumpler
Statutory Authority:
§ 1902(a)(3), Title
				  XIX, Social Security Act;
				  42 C.F.R. §§
											431.200 -
				  431.245;
				  §
										41-22-12, Alabama Administrative
				  Procedure Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-3 - FAIR HEARINGS › Section 560-X-3-.05 - Documentary Hearing Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Documentary Hearings are based solely
			 upon the written or printed evidence presented to the Hearing Officer by both
			 the complainant and the agency. Complainants should therefore submit
complete records
of all claims filed, correspondence,
			 rejections, forms and attachments at the time the original written request for
			 a hearing is forwarded to the agency.
Author:
William O. Butler.
Previous Rule No. 560-X-3-.05 entitled "Hearing on the
				  Record Procedures" effective October 1, 1982.
Amended
effective
				  April 11, 1985.
Repealed
effective January 1,
				  1986.
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-3 - FAIR HEARINGS › Section 560-X-3-.06 - Action By Agency On Hearing

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Prompt, definitive, and final
			 administrative action will be taken within sixty (60) days between the request
			 for a hearing and the rendering of the decision, unless there are extenuating
			 circumstances that require additional time. If the hearing is not completed
			 within 60 days, the recipient or provider will be notified of the reason for
			 the delay. In any event, final administrative action will be taken within
			 ninety (90) days from the date of request for a hearing. The complainant will
			 receive written notification of the decision.
(2) Recommendations of the Hearing Officer
			 shall be based exclusively on evidence and other material introduced at the
			 hearing. A verbatim transcript of testimony and exhibits, or an official report
			 by the Hearing Officer containing the substance of what transpired at the
			 hearing, together with all papers and requests filed in the proceeding and the
			 Hearing Officer's recommendations, shall constitute the exclusive record for
			 decision on a live hearing and shall be available to the complainant at any
			 reasonable time. The storage, proper maintenance and security of such records
			 shall be the responsibility of the Director, Hearings, Alabama Medicaid
			 Agency.
(3) Adverse decisions
			 approved by the Commissioner, as the hearing authority, shall contain a
			 statement that rehearing and/or judicial review of this decision is available
			 pursuant to the provisions of the Alabama Administrative Procedure Act. The
			 Commissioner shall notify the requestor, in writing regarding the hearing
			 decision.
Authors:
Robert R. Crumpler; William O.
				Butler.
Statutory Authority:
§ 1902 (a)(3), Title
				  XIX, Social Security Act;
				  42 C.F.R. §
											431.200 -
				  431.245;
				  §
										41-22-17, Alabama Administrative
				  Procedure Act.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-3 - FAIR HEARINGS › Section 560-X-3-.07 - Denial Of A Hearing

Current through Register Vol. 42, No. 9, June 28, 2024
(1) If
			 the request tor a hearing, in the opinion of Medicaid legal counsel, presents
			 only a legal issue, and the validity of the controlling law or regulation is
			 not challenged in the hearing request, a fair hearing request may be
			 denied.
(2) If eligibility of a
			 provider or a recipient has been terminated because of a criminal conviction
			 for Medicaid fraud or abuse, or if a provider has been terminated because of
			 loss of required licensure, then no fair hearing need be given. A certified
			 copy of the judgement of conviction or of the decision to revoke or suspend a
			 provider's license shall be conclusive proof of ineligibility for further
			 participation in the Medicaid Program. The pendency of an appeal for any such
			 conviction or license revocation or suspension shall not abate the termination
			 of Medicaid eligibility. If a conviction, or license revocation or suspension
			 is reversed on appeal, the recipient or provider may apply for reinstatement to
			 the Medicaid program. However, the reasons for the reversal will be scrutinized
			 by Medicaid and reinstatement will be at the sole discretion of the
			 Commissioner.
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-4 - PROGRAM INTEGRITY DIVISION › Section 560-X-4-.01 - General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The Program
			 Integrity Division is responsible for planning, developing, and directing
			 Agency efforts to identify, prevent, and prosecute fraud, waste and/or abuse in
			 the Medicaid Program. This includes verifying that medical services are
			 appropriate and rendered as billed, that services are provided by qualified
			 providers to eligible recipients, that payments for those services are correct,
			 and that all funds identified for collection are pursued.
(2) Federal regulations require the State
			 Plan for Medical Assistance to provide for the establishment and implementation
			 of a statewide surveillance and utilization control program that safeguards
			 against unnecessary or inappropriate utilization of care and services and
			 excess payments. The Alabama Medicaid Agency (Medicaid) has designated the
			 Program Integrity Division to perform this function. The division is
			 responsible for detecting fraud, waste, and/or abuse within the Medicaid
			 Program through reviewing paid claims history, reviewing provider and recipient
			 enrollment applications, and conducting field reviews and investigations to
			 determine provider/recipient abuse, waste, and suspicion of fraud. In addition,
			 the division is utilized to aid in program management and system improvement to
			 prevent fraud, waste and/or abuse in the Medicaid Program.
(3) Cases of suspected recipient fraud are
			 referred to local law enforcement authorities for prosecution upon completion
			 of investigation. Cases of a credible allegation of provider fraud and nursing
			 home patient account abuse are referred, upon completion of a preliminary
			 investigation, to the Medicaid Fraud Control Unit in the Alabama Attorney
			 General's Office which was established under Public Health 95-142 and Health
			 and Human Services guidelines to conduct full investigations for possible
			 prosecution, alleged provider fraud and nursing home patient account abuse in
			 the Medicaid Program.
(4) The
			 Utilization Review Committee (URC) is established under the authority of Code
			 of Alabama (1975) Section
			 22-6-8. This Committee reviews
			 cases of suspected provider or recipient fraud or abuse and recommends
			 appropriate sanctions. (Refer to sections
			 560-X-4-.04 and
			 560-X-4-.05)
Author:
Jacqueline G. Thomas, Director, Program
				  Integrity Division
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. Parts 431, 455, 456, 1000, 1001, 1001, 1002,
				  State Medical Manual 11420.6M.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-4 - PROGRAM INTEGRITY DIVISION › Section 560-X-4-.02 - Purpose

Current through Register Vol. 42, No. 9, June 28, 2024
The purpose of the Program Integrity Division is:
(1) To guard against fraud, waste, and/or
			 abuse of Medicaid program benefits by individual providers and
			 recipients;
(2) To assure that
			 Medicaid recipients receive necessary medical care at a level of quality
			 consistent with that available to general population;
(3) To exercise necessary fiscal control over
			 federal and state tax dollars;
(4)
			 To assure provider and recipient compliance with federal and state Medicaid
			 rules and regulations; and
(5) To
			 assist in the identification of claims processing procedures that may be in
			 conflict with State policy.
Author:
Jacqueline G. Thomas, Director, Program
				  Integrity Division
Statutory Authority:
State Plan; Title XIX,
				  Social Security Act; 42 C.F.R. §§ 431, 455, 456, 1000, 1001, 1002 ;
				  State Medical Manual 11420.6M.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-4 - PROGRAM INTEGRITY DIVISION › Section 560-X-4-.03 - Method

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Acquire,
			 organize, and analyze data.
(2)
			 Present computer results through special reports that will enable Program
			 Integrity to accomplish the following:
(a)
			 Develop a comprehensive statistical profile of health care delivery and
			 utilization patterns.
(b) Reveal
			 suspected instances of potential fraud, waste, and/or abuse by individual
			 practitioners, providers, recipients, or sponsors of recipients.
(c) Provide information indicating the
			 existence of any potential deficiencies in the level of care or quality of
			 services provided under the Medicaid Program.
(d) Provide information indicating the
			 existence of any potential deficiencies in State resolution
			 procedures.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-4 - PROGRAM INTEGRITY DIVISION › Section 560-X-4-.04 - Fraud, Waste, And/Or Abuse By Providers

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Fraud is defined as an intentional
			 deception or intentional misrepresentation made by a person with the knowledge
			 that the deception could result in some unauthorized personal benefit or
			 unauthorized benefit to some other person. Fraud is dependent upon evidence
			 that must substantiate misrepresentation with intent to illegally obtain
			 services, payment, or other gains.
(2)
Code of Ala.
			 1975
, Section
			 22-1-11 makes it a felony offense
			 to falsify a claim or application for payment of Medicaid benefits or offer,
			 pay, solicit or receive kickbacks, bribes, or rebates for services. Convictions
			 for any of these felonious actions could result in a fine of $10,000 or
			 imprisonment for one to five years for each violation.
(3) Providers participating in the Alabama
			 Medicaid Program shall make available, free of charge, the necessary records
			 and information to Medicaid investigators, members of the Attorney General's
			 staff, or other designated Medicaid representatives who, in the course of
			 conducting reviews or investigations, have need of such documentation to
			 determine fraud, abuse and/or other deliberate misuse of the Medicaid
			 program.
(4) The Medicaid Fraud
			 Control Unit of the Attorney General's Office may refer providers to Medicaid
			 for administrative sanctions because:
(a) The
			 dollar amount of the fraud involved does not warrant the expense of
			 prosecution; or
(b) Evidence of
			 willful intent to defraud is lacking, although evidence of abuse is
			 present.
Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-4 - PROGRAM INTEGRITY DIVISION › Section 560-X-4-.05 - Fraud, Waste, And/Or Abuse By Recipients Or Sponsors Of Recipients

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Recipient
			 fraud, waste, and abuse cases include, but are not limited to, the following
			 categories:
(a) Drug overutilization or
			 overutilization of services;
(b)
			 Sale, alteration, or lending of the Medicaid card to others for
			 services;
(c) Criminal activity
			 involved in securing medical services (such as forged prescriptions);
(d) Repeated failure to safeguard the
			 Medicaid card;
(e) Collusion with
			 providers for services or supplies;
(f) Providing incorrect information or
			 allowing others to do so in order to obtain Medicaid eligibility;
(g) Failure to reveal to Medicaid the
			 existence of third party insurance, failure to pay to Medicaid funds received
			 from "Third Parties" as required by Chapter 20 of these Codes, or failure in
			 other respects to cooperate with Medicaid in its effort to secure the State's
			 subrogation rights; or
(h) Failure
			 to report changes which occur in income, living arrangement, or
			 resources.
(i) Inappropriate use of
			 Medicaid voucher payments through the Non-Emergency Transportation
			 Program.