reglab/statecodes huggingface dataset:
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.04 - Statement of Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) A
			 statement of medical services shall be made in accordance with standard coding
			 methodology as established by the ICD-10-CM, HCPCS, and CPT-4 coding manuals
			 and prevailing adjudication rules in
Code of Ala.
			 1975
, §
								25-5-1(15).
			 Unbundling, fragmenting charges, duplicating, over-itemizing coding, upcoding,
			 unrelated charges, or engaging in any other practice for the purpose of
			 inflating bills for reimbursement shall be prohibited.
(2) Any reference in these Rules to any
			 specific CPT-4 code, HCPCS code, or ICD-10-CM code is not intended to restrict
			 or limit any provider's scope of practice, but is used for clarification only
			 within the context of the specific section in which it appears. When specific
			 codes are used in these Rules, the code reference shall refer to the most
			 current description of the specific code or successor to such code as
			 referenced in the most current edition of the coding manuals described in Rule
			 480-5-5-04(i).
(3) Medical services
			 shall be billed by the provider using the provider's usual, customary and
			 reasonable charges, although appropriate reimbursement shall be limited to the
			 prevailing reimbursement as ascertained by the Department and published in the
			 most current appropriate provider Maximum Fee Schedule; or as established
			 through negotiated agreements between the Department and participating
			 hospitals; or as established by statutory committee for nonparticipating
			 hospitals; or according to any mutually agreed upon reimbursement in accordance
			 with
Code of Ala. 1975
, §
								25-5-314.
(4) All bills may be subject to audit for
			 verifying services rendered.
(5)
			 Billing for subsequent medical services shall not include repeat billing for
			 medical services previously performed and billed.
Author:
Workers' Compensation Medical Services
				  Board
Statutory Authority:
Code of Ala.
				  1975
, §
										25-5-293.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.05 - Entity Qualified to Perform Bill Screening

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The following criteria shall be used by
			 the Department of Industrial Relations to qualify an employer/agent who may
			 perform the bill screening of medical services for workers' compensation
			 claims. This entity shall be qualified by the Department as required in Rule
			 480-5-5-.05 and/or
			 480-5-5-.06, as applicable, of
			 these rules. This entity shall:
(a) Be
			 familiar with medical terms;
(b) Be
			 familiar with the ICD-10-CM, CPT-4, and HCPCS Coding Manuals and Alabama
			 Department of Industrial Relations Administrative Code Utilization Management
			 and Bill Screening Chapter, and reimbursement as published in the most current
			 Alabama Workers' Compensation Maximum Fee Schedule according to provider
			 type;
(c) Be familiar with
			 prevailing adjudication rules;
(d)
			 Protect the confidentiality of medical records; and
(e) Provide a name and telephone number of a
			 person for the Department to contact Monday through Friday during normal
			 business hours, except legal holidays.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.06 - Utilization Review Entity Qualified To Perform Utilization Review

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Technical
			 Reviewer:
(a) It is the express intent of
			 these rules that approval of medical services may be performed by the
			 employer/agent or its designated employee who meets the requirements of Rule
			 480-5-5-.05. The technical
			 reviewer shall not deny a medical service related to an accepted compensable
			 claim but shall refer any medical services which may not be approved to the
			 first level of clinical review.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.07 - Utilization Review Process

Current through Register Vol. 42, No. 9, June 28, 2024
(1) It
			 is the express intent of these Rules that Utilization review may be performed
			 by the insurance carrier, employer/agent, self-insured employer, or group
			 self-insurance fund. There is no requirement that outside utilization review
			 entity vendors be hired to perform utilization review activate din accordance
			 with these Rules. Entities qualified by the Department may perform certain
			 functions as herein described and permitted by these Rules.
(2)
Technical Reviewer
- It is
			 the express intent of these Rules that approval of medical services may be
			 performed by the employer/agent, or its designated employee which may include,
			 but is not limited to, the Technical Reviewer. The employer/agent or designated
			 employee shall not deny a medical service but shall refer any medical services
			 which may not be approved to the first level of clinical review.
(3)
First Level Clinical Review
- Medical services that do not meet the criteria for first level clinical
			 review shall be referred to the second level of review prior to
			 anon-certification or denial determination.
(4)
Second Level Clinical
			 Review:
(a) If the physician performing
			 the second level clinical review is not a peer to the ordering physician and a
			 decision to approve the request cannot be rendered, the second level clinical
			 reviewer shall:
1. Notify the requesting
			 provider that up to 48 hours will be allowed for the purpose of a review by the
			 requesting provider's peer, and
2.
			 Refer the request for a review by the requesting provider's peer.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.08 - Pre-Certification Required

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Application for pre-certification shall be made as early as possible by the
			 provider prior to rendering of the medical services for a compensable illness
			 or injury. If medical services are for treatment of a medical emergency,
			 notification shall be made by the provider to the employer/agent no later than
			 the next working day.
(2) The
			 following medical services shall require authorization and pre-certification to
			 be eligible for reimbursement:
(a)
			 Non-emergency admissions to inpatient facilities of any type including, but not
			 limited to skilled nursing facilities;
(b) Elective medical services performed in an
			 ambulatory surgery center or the outpatient surgery department of a hospital or
			 as part of an inpatient admission;
(c) Outpatient physical therapy, occupational
			 therapy and speech therapy services;
(d) Chiropractic services;
(e) Repeat baseline diagnostic studies where
			 the clinical condition of the patient is unchanged since the initial study, and
			 the initial study is available to the specialist in an appropriate time
			 frame;
(f) Cases selected by the
			 employer/agent for focused medical management, which may include, but not be
			 limited to, referrals to a specific specialist;
(g) Home health care;
(h) Home I.V. therapy;
(i) Pain management or outpatient pain
			 clinics;
(j) Work
			 hardening;
(k) Work conditioning;
(l) Durable medical equipment
			 (other than braces, splints, etc., routinely provided in physician's office)
			 including all items exceeding a reimbursement of $500.00, all Transcutaneous
			 Electrical Nerve Stimulation (TENS) units, and all rental items;
(m) Biofeedback;
(n) Chemical dependency outpatient
			 programs;
(o) Weight loss programs
			 or clinics;
(p) Non-emergency
			 dental services of all types;
(q)
			 Magnetic Resonance Imaging (MRI);
(r) Computerized Axial Tomography (CAT)
			 scans;
(s) Myelograms, discograms,
			 or surface electromyograms;
(t)
			 Psychiatric or psychological therapy or testing resulting from a compensable
			 injury or trauma;
(u) Video
			 fluoroscopy;
(v)
			 Epidurals;
(w) Stellate Ganglion
			 Blocks; and
(x) Beryllium
			 Blocks.
(y) Ambulance
			 Services
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.09 - Procedures of Pre-Certification

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Pre-certification review shall be
			 conducted by telephone and/or facsimile during normal business hours (8:30 a.m.
			 to 4:30 p.m. Central time, Monday through Friday, excluding legal holidays).
			 Written requests may be processed by the RUE or employer/agent on a case-by
			 case basis.
(2) The physician,
			 hospital, or other provider shall initiate the process by calling the
			 employer/agent at least 48 hours or two working days in advance, except for an
			 emergency. The RUE or employer/agent shall respond with a review determination
			 to the physician, hospital, or other provider-within 48 hours or two working
			 days after the receipt of necessary information. If a patient does not enter
			 the hospital or receive other medical services on the proposed date or within
			 15 days following that date, rectification shall be required. In such cases,
			 the caller shall contact the RUE or employer/agent to reaffirm the previously
			 submitted data for recertification.
(a) The
			 provider shall supply the following information to the employer/agent:
1. Employee's name;
2. Employee's identifying number;
3. Date of injury;
4. Employee's address;
5. Sex;
6. Employee's date of birth;
7. Name of provider or facility;
8. Provider's or facility's
			 address;
9. Anticipated treatment
			 or admission date;
10. Diagnosis
			 (to include ICD-10-CM codes);
11.
			 Expected length of stay, if applicable;
12. Major procedures and related CPT 4
			 codes;
13. Plan of
			 treatment;
14. Complications or
			 other factors requiring the setting requested;
15. Medical justification for planned
			 treatment or inpatient admission;
16. Anticipated surgical procedure, if
			 any;
17. General anesthesia
			 requirement;
18. Attending
			 physician's name;
19. Attending
			 physician's address;
20. Attending
			 physician's phone number;
21.
			 Attending physician's tax ID or identifying number;
22. A brief summary of how the proposed
			 procedure is related to the patient's work related injury; and
23. Caller's name and number.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.10 - Continued Stay Review Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The RUE or employer/agent is responsible
			 for initiating the medical necessity review for continued hospitalization
			 before the initial assigned length of stay expires. The responsibility to
			 request an extension may be delegated to the hospital, if requested by the
			 hospital and agreed to in writing by the RUE or employer/agent.
(2) Continued stay review shall include
			 telephone/on-site discussions/review with the hospital, or with the physician
			 for the information required. All pertinent information necessary to determine
			 if continued hospitalization is medically necessary shall be gathered (i.e.,
			 treatment, diagnosis, current medications and methods of administration used,
			 frequency, lab values, and results of diagnostic tests).
(a) If continued stay is appropriate,
			 additional days shall be based upon the medical condition of the patient and
			 the treatment plan. This process shall continue until the patient is
			 discharged.
(b) If continued stay
			 is not medically necessary or appropriate, based upon documentation reviewed,
			 the reviewing physician, Second Level Clinical Review as defined in Rule
			 480-5-5-.06(3),
			 shall issue a denial to the physician and hospital the same day of the
			 review.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.11 - Technical Considerations For Review (Bill Screening) Of Claims

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Prior to a
			 detailed medical review, a review of the claim shall be accomplished as a part
			 of the initial bill screening process and shall include at least the following:
(a) Identifying the job related
			 illness/injury;
(b) Identifying
			 each service/item billed;
(c)
			 Identifying the billing period;
(d)
			 Determining that appropriate forms were used and filled out
			 completely.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.12 - Physician Of Record

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 employer's authorized treating physician (other than emergency medical
			 services) shall be the physician of record for attending or referral purposes.
			 All referrals shall be pre-approved by the employer/agent. The employer/agent
			 shall keep all interested parties involved in the compensable case informed of
			 any authorized change of treating physician.
Author:
Workers' Compensation Medical Services
				Board
Statutory Authority:
Code of Ala.
				  1975
, §
										25-5-293.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.13 - Emergency Care

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Emergency
			 Services - The provider who provides care under the "medical emergency"
			 exception shall demonstrate that "emergency services" occurred as defined in
			 Rule 480-5-5-.02.
Author:
Workers' Compensation Medical Services
				Board
Statutory Authority:
Code of Ala.
				  1975
, §
										25-5-293.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.14 - Second Or Opposing Surgical Opinion

Current through Register Vol. 42, No. 9, June 28, 2024
(1) When elective surgery has been
			 recommended by the treating physician, the employee, subject to the limitations
			 of
Code of Ala. 1975
, §
								25-5-77(b), or
			 the employer/agent is entitled, but not required, to obtain a second
			 professional opinion from a physician board certified in the same or similar
			 specialty or the specialty that normally treats the patient's condition.
(a) Regardless of the second opinion, the
			 employee remains free to elect not to undergo surgery after the consultation,
			 subject to the possibility of denial of benefits for refusal of said
			 surgery.
(b) The employer/agent
			 shall be responsible for informing the employee when a second surgical opinion
			 is requested and for referring the employee to second surgical opinion
			 physician.
(c) The designated
			 physician of record shall be notified of the request in order to assist the
			 coordination of related medical services. There shall be no duplication of
			 medical services.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.15 - Bill Screening

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
Global Surgery Fees -
Ongoing services prior to surgery shall be
			 covered on a fee-for-services basis. The global surgery allowance shall
			 encompass the actual surgery procedure and normal post-operative services.
			 Post-operative visits after six weeks from the date of surgery shall be
			 reimbursable separately. The six week global period applies only to those codes
			 which have been assigned a 90-day global period by Medicare. Global surgery
			 fees include specialty surgical techniques such as, but not limited to, the use
			 of microscopes, videoscopes or lasers, with the exception of unusual situations
			 or extremely long procedures. Reimbursement, in such cases, shall be handled
			 with appropriate individual consideration for the circumstances. A separate
			 charge for a history and physical examination shall be reimbursable for new
			 patients. Global surgery fee includes any anesthesia administered by the
			 operating surgeon.
(2)
Multiple Surgery Procedures
(a)
			 For operations performed by the same physician during the same operative
			 session, at the same operative site, reimbursement shall be made at 100 percent
			 (100%) for the procedure with the highest Workers' Compensation fee schedule
			 allowance and 50 percent (50%) of the approved rate for all additional
			 procedures which are medically necessary and not incidental to the
			 other.
(b) For unrelated operations
			 performed by the same physician in different body areas or systems during the
			 same operative session, the multiple procedure reimbursement rule shall apply
			 independently to each body system when the procedures are medically necessary
			 and not incidental to the other procedures.
(c) When bilateral procedures that require
			 preparation of a separate operative site during the same operative session are
			 performed by the same physician, aggregate reimbursement shall be 180 percent
			 (180%) of the allowance of the unilateral procedure.
(d) Certain codes, by the nature of their
			 description, are never to be billed as primary procedures. The value assigned
			 in the fee schedule has already been reduced as a secondary procedure and,
			 therefore, the procedure should be reimbursed at 100 percent (100%) of the
			 allowance. These codes may be identified by the description in the CPT manual
			 specifying each additional service, i.e., 11001, 63091, 63057.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.16 - Conflict Of Interest: Health Facility Owner-Ship By A Provider

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All providers
			 or payors performing or making referrals of workers' compensation cases to
			 facilities in which the provider has an ownership interest, financial interest
			 or fiduciary interest, shall notify the carrier, provider or their respective
			 agent of such interest at the request of the employer, carrier or their
			 respective agent.
Author:
Workers' Compensation Medical Services
				Board
Statutory Authority:
Code of Ala.
				  1975
, §
										25-5-293.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.17 - Optometric Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Covered Expenses
(a) Only services and
			 products necessitated by an on-the-job injury or illness shall be covered. Such
			 services and, or products shall be provided as a result of damage to the eye(s)
			 due to a work injury or exposure. In addition, lenses and contact lenses not
			 originally purchased by the employer shall be repaired or replaced if damaged
			 or broken in a work-related accident.
(b) There are three distinct types of covered
			 services:
1. Professional;
2. Optical Fitting; and
3. Eye Appliance.
(c) The reimbursement allowed for contact
			 lenses shall include the normal follow-up to check for proper fit, vision
			 correction and comfort. Any other follow-up services routinely provided free of
			 charge by the provider to other patient or customers shall be provided free of
			 charge to workers' compensation claimants.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.18 - Chiropractic Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Initial Evaluation
(a) An evaluation shall be
			 performed to determine if a patient will benefit from chiropractic
			 services.
(b) Where a chiropractor
			 examines a patient and an evaluation for chiropractic services is performed,
			 the billing of the office visit shall include the initial evaluation.
(c) For acute cases, up to three (3) visits
			 during the certification process may be allowed after the initial evaluation,
			 if same day certification cannot be obtained. If subsequent pre-certification
			 results in an adverse determination, reimbursement shall be allowed for the
			 initial evaluation and up to three visits during the certification period, if
			 medically necessary and the treatment is for a c compensable injury.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.19 - Physical Therapy/Occupational Therapy/Speech Therapy Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Applicability -
			 The following shall apply to non-physician therapy providers (hospital
			 outpatient, freestanding, and independent practicing facilities). Practicing
			 physical therapists, physical therapist assistant, occupational therapists,
			 occupational therapists assistants and speech therapists shall be currently
			 licensed or certified.
(2) The
			 following criteria shall be met for therapy to qualify for reimbursement:
(a) The patient's condition shall have the
			 potential for restoration of function and require a skilled level of
			 care;
(b) The therapy shall be
			 specific for the improvement of the patient's condition;
(c) The therapy shall be provided under a
			 current plan of care which is developed by the therapist, a copy of which is
			 sent to and approved by the referring physician and substantiated in the
			 physician's office notes and in the therapist's office notes; and
(d) The referring physician shall concur, and
			 upon request, submit to the employer/agent or RUE documentation substantiating
			 the medical necessity of therapies ordered.
(e) For acute cases, up to three (3) visits
			 during the certification process may be allowed after the initial evaluation,
			 if same day certification cannot be obtained. If subsequent pre-certification
			 results in an adverse determination, reimbursement shall be allowed for the
			 initial evaluation and up to three visits during the certification process, if
			 the treatment is medically necessary and is for a compensable work
			 injury.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.21 - Prescribed Medications

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
Prescribed Medication Services
(a) "Medicinal drugs" or "drugs" shall be
			 defined as "legend" or "prescription" drugs that may only be dispensed when
			 prescribed by a currently licensed provider authorized by law to prescribe
			 drugs.
(b) "Medicines" shall be
			 defined as drugs prescribed by an authorized health care provider and include
			 generic drugs or single-source patented (brand name) drugs for which there is
			 no generic equivalent.
(c) Whenever
			 medically appropriate, a pharmaceutical and therapeutically equivalent drug
			 product may be selected by a physician or other authorized practitioner in
			 accordance with the requirements of
Code of Ala. 1975
,
			 §
									34-23-8.
(d) Reimbursement
1. Reimbursement to the provider shall not
			 exceed the amount calculated by the pharmaceutical reimbursement formula for
			 prescribed drugs as specified in the Maximum Fee Schedule for
			 Pharmaceutics.
2. The provider
			 shall bill for prescription drugs or "medicines" on the appropriate form as
			 stated in Rule
			 480-5-5-.22.
(e)
Reimbursement
			 Formula/Methodology
1. The
			 pharmaceutical reimbursement formula for prescribed drugs is contained in the
			 Maximum Fee Schedule for pharmaceutics.
(1)
			 Average Wholesale Price (AWP) shall be determined from the most recent issue,
			 including updates, of Drug Topics Red Book, Prescription Pricing Guide,
			 American Druggist Blue Book, or similar pharmaceutical publications.
(ii) The reimbursement amount shall be
			 determined by multiplying the AWP by the percent factor as published in the
			 Maximum Fee Schedule for Pharmaceutics and adding the dispensing fee.
(2) "Patent" or "Proprietary
			 Preparations"
(a) Billing
1. Pharmacists shall bill and be reimbursed
			 their usually and customary charge for any "over-the-counter drug."
2. The reimbursement formula shall not apply
			 to "over-the-counter drugs" and no dispensing fee shall be
			 reimbursed.
3. The following data
			 shall appear on the billing form:
(i)
			 Employee's Name;
(ii) Employee's
			 Address;
(iii) Employee's
			 Identifying Number;
(iv) Date
			 Prescription was Filled;
(v)
			 Prescription Number;
(vi) National
			 Drug Code;
(vii) Drug
			 Name;
(viii) Drug
			 Quantity;
(ix) Total
			 Charge;
(x) Employee's or
			 Pharmacist's Signature; and
(xi)
			 Provider's Name and Address.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.22 - Approved Standardized Medical Reimbursement Forms

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The following approved standardized
			 reimbursement forms shall be used by providers as indicated below. Each form
			 shall be completed in its entirety and shall comply with the Alabama Maximum
			 Fee Schedule coding, if available.
(a)
			 Providers: physicians; optometrists; chiropractors; durable medical equipment
			 suppliers; diagnostic facilities; laboratory facilities; independently based
			 speech therapy, physical therapy, and occupational therapy centers; home health
			 providers; and other professional medical services. Professional medical
			 services provided pursuant to Rule
			 480-5-5-.20(2)(e),e.g.,
			 medical doctors, physical therapists, etc.
1.
			 Form: HCFA 1500 as currently revised with all subsequent revisions. Office
			 notes and/or supporting documentation directly relating to the services
			 provided are required to be attached to the HCFA 1500.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.23 - Appeals Process For Utilization Review Bill Screening, Peer Clinical Review And Denial Or Revocation Of Utilization Review Certificate

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Adverse
			 decisions rendered under Rule
			 480-5-5-.08 or
			 480-5-5-.10 regarding medical
			 necessity shall be subject to peer review and/or administrative appeal at the
			 request of any party as follows:
(a) Peer
			 Clinical Review
1. All UREs or
			 employers/agents shall have in place an appeal process through Peer Clinical
			 Review (Third Level clinical Review) when an adverse decision is
			 rendered.
2. The Peer Clinical
			 Review (Third Level Clinical Review) process shall be initiated by the provider
			 contacting the RUE or employer/agent by telephone or other immediate means
			 following receipt of the decision to be followed by a written request that
			 shall include medical records and/or data needed to reach a decision.
3. The Peer Clinical Review (Third Level
			 Clinical) request shall be evaluated in accordance with Rule
			 480-5-5-.07. The reviewer shall
			 make a decision within 30 calendar days, unless an expedited appeal pursuant to
			 Rule 480-5-5-.07 is required.
(i) If the Peer Clinical Review (Third Level
			 Clinical Review) decision is a reversal of noncertification or denial, the
			 admitting physician, hospital or other provider shall be immediately notified
			 via telephone and a follow-up letter or facsimile shall be sent to the
			 physician, hospital or other provider.
(ii) If the Peer Clinical Review (Third Level
			 Review) decision upholds noncertification or denial, the adjudicator shall
			 verbally notify the admitting physician, hospital or other provider and shall
			 immediately submit in writing the denial and case documentation to the
			 requesting party and any other provider involved in the case.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.24 - Discharge Planning Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Discharge planning shall be the joint
			 responsibility of the RUE or employer/agent and the facility. The RUE or the
			 employer/agent shall work with the facility's discharge planning department to
			 ensure continuity of care as directed by the physician from the facility to the
			 alternative care setting.
(2) The
			 facility shall identify to the RUE or employer/agent patients who need
			 discharge planning. The RUE or employer/agent shall identify and assist the
			 facility with information on statutory coverage and alternative providers, and
			 monitor facilities to assure that appropriate discharge planning services are
			 provided. The facility discharge planning department shall recommend to the RUE
			 or employer/agent medically necessary services are resources which will ensure
			 continuity of care from the facility to the alternative care setting.
(3) The RUE or employer/agent shall require
			 appropriate facility documentation on cases processed.
Author:
Workers' Compensation
				Division
Statutory Authority:
Code of Ala.
				  1975
, §
										25-5-293.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.25 - On Site Audit

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Audit
			 disputes between the RUE or employer/agent and billing party may be referred to
			 the Workers' Compensation Ombudsman Program for medical dispute resolution in
			 accordance with
Code of Ala. 1975
, §
								25-5-77(i).
(2) RUE or Employer/Agent Responsibilities
(a) The services to be audited shall be
			 identified within fourteen (14) working days after the RUE or employer/agent
			 receives the approved standard reimbursement form as stated in Rule
			 480-5-5-.22.
(b) The RUE or employer/agent or its audit
			 firm shall make an appointment to do the audit at a time that is mutually
			 agreeable, but no later than 30 days from receipt of the written request. At
			 the time the appointment is made, the provider shall be informed of:
1. The name(s) of patient(s) whose records
			 are to be audited.
2. The
			 admission, discharge or treatment dates for each case.
3. The medical record numbers and billing
			 numbers of the claims to be audited, as assigned by the billing party, if those
			 appear on the claim.
4. The name(s)
			 of the auditor(s) who will conduct the audit, if available, and the name of the
			 audit firm if the RUE or employer/agent is contracting for auditing
			 services.
5. The portion of the
			 bill to be audited (i.e., drugs, respiratory therapy, etc.) if the entire bill
			 is not to be audited.
(c) The auditor shall be a first level
			 clinical reviewer familiar with billing practices, medical terminology and
			 medical record charting if billing audit is done by the RUE or
			 employer/agent.
(d) Auditors shall
			 be properly authorized and identified as representatives of the RUE or
			 employer/agent, or its audit firm.
(e) The RUE or employer/agent shall pay at
			 least 80 percent (80%) of the reimbursement rate methodology, see Rule
			 480-5-5-.04, prior to the audit.
			 If an audit fee is charged by the provider, it shall not exceed $50.00 per
			 patient record plus copy charges, if copies are requested, in accordance with
			 1994 Alabama Act 609.
(f) Auditors
			 shall itemize specific unsupported charges and unbilled charges found on
			 provider bills. The final audit findings shall offset unbilled charges against
			 unsupported charges in a reconciliation process that shall be completed by the
			 RUE or employer/agent after receiving the audit report that shall include a
			 listing of all unbilled charges and unsupported billings.
(g) Auditors shall conduct an exit interview
			 with the provider's audit coordinator and/or other appropriate personnel prior
			 to leaving to permit review of the preliminary audit results before issuing a
			 final report. If the exit interview is waived by the provider, this fact shall
			 be indicated in writing.
1. A written report
			 of the final audit results shall be sent to all interested parties within 25
			 working days.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.26 - Ambulatory Surgery Centers

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 When medically appropriate, surgical procedures may be performed on an
			 outpatient basis to reduce unnecessary hospitalization and to shift care to a
			 less costly setting in accordance with Rule
			 480-5-5-.11(3).
			 All freestanding Ambulatory Surgery Centers (ASCs) licensed in Alabama shall be
			 subject to the policies and methodology for determining reimbursement using the
			 Maximum Fee Schedule for Ambulatory Surgery Centers or according to any
			 mutually agreed reimbursement pursuant to
Code of Ala.
			 1975
, §
								25-5-314.
(a) ASC facility services shall be those
			 items and services provided by an ASC in connection with an authorized
			 procedure including:
1. Nursing, technician
			 and ancillary services;
2. Use of
			 the ASC facility for preoperative services, surgery, and postoperative
			 services;
3. Drugs, biologicals,
			 surgical dressings, supplies, splints, casts, appliances and equipment directly
			 related to the performance of a surgical procedure;
4. Diagnostic or therapeutic services or
			 items directly related to the performance of a surgical procedure;
5. Materials and supplies usually required
			 for the administration of anesthesia; and,
6. Administrative, record keeping, and house
			 keeping items and services.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.27 - Admission Review Procedures

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All nonelective acute care hospital
			 admissions including emergencies, psychiatric admission, and all extended
			 hospitalization shall be reviewed under generally accepted criteria.
Author:
Workers' Compensation
				Division
Statutory Authority:
Code of Ala.
				  1975
, §
										25-5-293.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.28 - Dental Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Basic
			 Information - The Rules set out in this chapter apply to providers rendering
			 dental and maxillofacial surgery services. Providers of these services shall
			 also, when applicable, follow the rules and policies in these Rules pertaining
			 to pre-certification, utilization review, bill screening, and claims
			 payment.
(2) Dental Services
(a) Dental codes and descriptors published in
			 the American Dental Associations' (ADA) Current Dental Terminology Manual
			 (CAT-2) shall be used for billing dental services.
(b) Dental procedures shall be identified by
			 the ADA's five-digit code.
(c)
			 Dental services may include professional consultations or visits in the office
			 or hospital.
(d) Dental services
			 shall be billed using the J510 (ADS85) form.
(e) Reimbursement for services rendered shall
			 be limited to the provider's charge, the Maximum Fee Schedule for Dentists, or
			 any mutually agreed upon reimbursement pursuant to
Code of Ala.
			 1975
, §
									25-5-314, whichever is
			 less.
(f) For dental procedures not
			 listed in the Maximum Fee Schedule for Dentists, reimbursement shall be based
			 on usual and customary charges in the area where the service is provided and
			 based on documentation submitted by the provider.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.29 - Medical Case Management

Current through Register Vol. 42, No. 9, June 28, 2024
(1)
			 Medical case management determination shall be the responsibility of the
			 employer/agent unless delegated. This service may be performed in conjunction
			 with utilization management; however, it is differentiated by its designation
			 to promote optimal recovery and physical rehabilitation by professional
			 involvement in the physical rehabilitation process.
(2) Since medical case management is an
			 integral components of a utilization management program, it shall, at the
			 discretion of the employer/agent, be used as a component in the physical
			 rehabilitation of the injured worker. The overall goal of medical case
			 management is to facilitate the organizing and sequencing of appropriate health
			 care services. This shall be done in the most cost effective manner without
			 compromising quality of care in order to promote optimal outcomes for all
			 parties involved.
(3) The
			 employer/agent is the responsible party for determining the necessity of
			 medical case management.
(4)
			 Individuals or entities performing medical case management shall comply with
			 the most current standards adopted by the International Association of
			 Rehabilitation Professionals (IARP), professional performance criteria for
			 medical case management, which pertains to workers' compensation cases or other
			 nationally recognized medical case management standards. Notwithstanding the
			 foregoing, nothing in this rule shall require a case manager to become a member
			 of any association with recognized standards used in medical case management.
(5) The dispute resolution process
			 shall be in accordance with Rule
			 480-5-5-.23.
Author:
Workers' Compensation Division
Statutory Authority:
Code of Ala.
				  1975
, §
										25-5-293.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.30 - Home Health Care Service

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Prior to the provision of medical
			 services, supplies or other non-medical services, the determination that the
			 illness, injury or condition is work related must be made and shall be
			 pre-certified as medically necessary and not for the convenience of the patient
			 and/or family.
(a) All nursing services and
			 personal care services shall have prior authorization by the
			 employer/agent.
(b) A description
			 of needed nursing or other attendant services, as well as specifying the level
			 of nursing care (R.N., L.P.N., sitter/nonprofessional), shall be included in
			 the request for authorization.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.31 - Pain Management Program

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Pain management program services shall
			 receive authorization from the employer/agent prior to providing services. No
			 health care provider may refer the employee to another pain management program
			 without prior authorization from the employer/agent.
(2)
Billing Information
(a) Pain management programs shall use the
			 appropriate billing forms as stated in Rule
			 480-5-5-.22 to bill for services
			 rendered. Any attachment to billing forms shall be labeled with the claimant's
			 name, identifying number and date of accident prior to submission to the
			 carrier.
(b) Pain management
			 program services shall be billed using a total or global charge concept. The
			 bill shall include charges for the performance of the basic professional
			 service and the normal range of essential, associated services provided to
			 achieve the objective of the program. Licensed personnel, including physicians,
			 serving as part of the interdisciplinary team, shall not bill separately for
			 their services.
(c) Any physician
			 or other provider serving on a consulting basis to the pain management program,
			 whose services have been authorized by the employer/agent in addition to the
			 interdisciplinary team's services, shall bill on the appropriate form as
			 defined in Rule
			 480-5-5-.22.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.32 - Durable Medical Equipment

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All services described in these rules,
			 except those specifically noted, shall have prior authorization of the
			 employer/agent before reimbursement shall be made. The authorized treating
			 physician shall state that the condition was indeed work-related and that the
			 durable medical equipment is medically necessary. Each authorization request
			 shall include a prescription or statement of need from the authorized treating
			 physician.
(2) If a claimant is
			 receiving treatment for both compensable and noncompensable medical conditions,
			 only those services provided in treatment of compensable conditions shall be
			 listed on claims and invoices submitted to the employer/agent. In addition,
			 items covered by private payers for noncompensable conditions shall not be
			 listed on invoices submitted to the employer/agent.
(3) Durable Medical Equipment (DME) refers to
			 those items which can withstand repeated use, are primarily used to serve a
			 medical purpose, are generally not useful to a person in the absence of
			 illness, injury or disease, and are appropriate for use in the claimant's home.
(a) The employer/agent reimburses for the
			 purchase or rental of certain medical equipment and accessories and the
			 purchase of certain medical supplies for the claimant's use in a
			 noninstitutional setting.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.34 - Ambulance Services

Current through Register Vol. 42, No. 9, June 28, 2024
(1) All
			 non-emergency ground and air ambulance service rendered to workers'
			 compensation claimants shall be pre-certified. Emergency ground and air
			 ambulance services shall be retro-certified within 24 hours of the service or
			 on the next working day.
(2) All
			 ground and air ambulance services shall be medically necessary and appropriate.
			 Documentation, trip sheet(s), shall be submitted with the bill that states the
			 condition(s) that indicates the necessity of the ground or air ambulance
			 service provided. It should readily indicate the need for transport via this
			 mode rather than another form of transportation. The service billed shall be
			 supported by the documentation submitted for review.
(3) Reimbursement shall be made if the
			 injured employee expires while enroute to or from a health care facility.
			 Reimbursement shall not be payable if the responding ambulance or air ambulance
			 service did not transport the injured employee, or if the employee was
			 pronounced dead by a legally authorized individual prior to
			 transport.
(4) Billing for services
			 shall be submitted to the payer on a properly completed HCFA 1500 claim form by
			 HCPCS code. Hospital based or owned providers must submit the charges on a HCFA
			 1500 by HCPCS code.
(5)
			 Reimbursement shall be:
(a) Based upon the
			 lesser of the submitted charge or the Prevailing Reimbursement/Maximum Fee
			 Schedule for Ambulances. These payments shall not exceed the prevailing charges
			 in that locality for comparable services under comparable circumstances;
			 and,
(b) Commensurate with the
			 services actually performed. Services rendered are independent of the type of
			 call received or the type of staff and/or equipped ambulance responding.
Author:
Workers' Compensation Medical Services
				Board
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.35 - Impairment Rating Guide

Current through Register Vol. 42, No. 9, June 28, 2024
(1) The
			 American Medical Association Guides to the Evaluation Of Permanent Impairment,
			 Fourth Edition, shall be the recommended guide used by physicians in
			 determining impairment and/or disability ratings.
Author:
Workers' Compensation Medical Services
				Board
Statutory Authority:
Code of Ala.
				  1975
, §
										25-5-293.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.36 - Time Limits For Employee Filing Incurred Expense Claims

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In accordance
			 with
Code of Ala. 1975
, Section
			 25-5-77(c), the
			 employer shall pay reasonable charges for the employee's necessary board,
			 lodging, and travel, if vocational rehabilitation requires residence at or near
			 a facility away from the employee's customary residence.
Code of
			 Ala. 1975
, Section
			 25-5-77(f)
			 requires the employer to pay mileage costs to and from medical and
			 rehabilitation providers at the same rate as provided by law for official state
			 travel.
(a) All mileage is subject to
			 verification.
(b) Claims for
			 mileage to a medical provider or rehabilitation that incurred between the
			 claimant's work location and normal residence shall not be eligible for
			 payment.
(c) Both mileages to drop
			 off a prescription and return mileage to pickup a prescription shall not be
			 reimbursable. Only one round trip shall be approved.
Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.37 - Out-Of-State Medical Providers

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Occasionally an employee, whose injury
			 falls under Alabama's jurisdiction, may require treatment by a medical provider
			 in another state. Alabama's fee schedules are developed under the premise that
			 treatment will be provided in this state. The hospital and ambulatory surgery
			 fee schedules are unique to that particular Alabama facility. Other Alabama
			 medical provider's reimbursement schedules are derived from the most common
			 payer of health care services in this state.
(2)
Code of Ala.
			 1975
, §
								25-5-77 limits the employer's
			 liability to the prevailing rate or maximum schedule of fees. Prevailing is
			 defined in
Code of Ala. 1975
, §
								25-5-1(15) and
Department of Industrial Relations Administrative
			 Code
, Rule
			 480-5-5-.02(61).
			 If another state has a workers' compensation schedule for that provider type,
			 that schedule constitutes the prevailing rate for treatment of a workers'
			 compensation injury.
(3) For any
			 injury under Alabama's jurisdiction, the out-of-state medical provider is paid:
(a) According to that state's workers'
			 compensation fee schedule for that provider;
(b) According to a mutually negotiated
			 payment rate pursuant to
Code of Ala. 1975
, §
									25-5-314; or
(c) According to the Alabama workers'
			 compensation fee schedule for non-facility medical providers.