Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-6 - PHYSICIANS PROGRAM › Section 560-X-6-.02 - Submission Of Claims: General

Current through Register Vol. 42, No. 9, June 28, 2024
(1) Effective March 1, 2010, all claims that
			 do not require attachments (TPL denial), manual review (unclassified J codes),
			 and an Administrative Review override by Medicaid or additional information to
			 be printed on the claim (Work Incentive Program) must be submitted
			 electronically to the Alabama Medicaid Agency fiscal agent. All paper claims
			 received by the Alabama Medicaid Agency fiscal agent which do not meet the
			 above requirements will be returned to the provider without being processed.
			 Paper claims meeting the requirements should be submitted on CMS-1500 (Health
			 Insurance Claim) forms. Each claim filed by a physician constitutes a contract
			 with Medicaid.
(2) For claim filing
			 limitations, refer to Chapter 1, Rule
			 560-X-1-.17.
(3) Physicians who want to participate in the
			 Alabama Medicaid Program must be enrolled and receive a provider
			 number.
(4) Claims must include the
			 name and NPI number of the physician who takes responsibility for the services.
			 The NPI number must identify the responsible individual, not a group or
			 institution. Reimbursement may be made to a physician submitting a claim for
			 services furnished by another physician in the event there is a reciprocal
			 arrangement. The regular physician shall identify the services as substitute
			 physician services by entering HCPCS modifier
Q5
(Service
			 Furnished by a Substitute Physician under a Reciprocal Arrangement) or HCPCS
			 modifier
Q6
(Service Furnished by a Locum Tenens Physician) after
			 the procedure code. The substitute physician must be enrolled with Medicaid as
			 an active provider. The reciprocal arrangement may not exceed 14 continuous
			 days in the case of an informal arrangement or 60 continuous days in the case
			 of an arrangement involving per diem or other fee-for-time compensation. The
			 regular physician should keep a record on file of each service provided by the
			 substitute physician and make this record available to Medicaid upon request.
			 Payment may not be made for services provided by providers who have been
			 suspended or terminated from participation in the Medicaid program. See Rule
			 No. 560-X-4-.04 for details. Claims
			 will be subject to post-payment review. Refer to the Alabama Medicaid Provider
			 Manual, Chapter 28 for information regarding modifiers Q5 and Q6.
(5) Incomplete or inaccurate claim forms
			 submitted for processing will be returned to the provider by the Medicaid
			 fiscal agent for the necessary information.
(6) Before submitting a claim, a careful
			 check should be made to see that the Medicaid identification number agrees with
			 the number and exact spelling of the name on the patient's plastic Medicaid
			 eligibility card.
(7) In filling
			 out claim forms, providers must use diagnosis codes from the ICD-9-CM diagnosis
			 codes (dates of services prior and up to September 30, 2015) or ICD-10-CM
			 diagnosis codes (dates of services October 1, 2015 and forward) and procedures
			 codes from the CPT Code Book, or approved procedures codes designated by
			 Medicaid.
(8) Factoring
			 arrangements in connection with the payment of claims under Medicaid are
			 prohibited.
(9) Medicaid's fiscal
			 agent will furnish to new providers a manual containing billing
			 instructions.
(10) Pharmacists must
			 have the physician's license number prior to billing for prescriptions. Refer
			 to Chapter 16.
(11) Fragmentation
			 of procedures, including laboratory procedures, under the Medicaid program is
			 prohibited.
Author:
Beverly Churchwell; Program Manager;
				  Medical Support
Statutory Authority:
Title XIX, Social Security
				  Act; 42 C.F.R. §§401,
et
seq
.; State Plan; Omnibus Budget Reconciliation Act of
				  1990 (Public law 1051508).