Alabama Administrative Code

(1) Only instate agencies are eligible for participation. (2) A home health agency is a public agency, private non-profit organization or proprietary agency which is primarily engaged in providing part-time or intermittent skilled nursing services and home health aide services to…

(1) A participating agency has the right to withdraw from the Medicaid program after giving written notice to Medicaid of its intent at least thirty (30) days in advance. (2) The state may terminate the home health agency's participation in the Medicaid program in cases involving…

(1) If ordered by the patient's physician or non-physician practitioner (NPP), and authorized by Medicaid, a professional registered nurse employed by a certified home health agency can provide part-time or intermittent nursing services to a patient. (a) The registered nurse is r…

(1) There is no coverage under the Medicaid Home Health care plan for visits by paramedical personnel, physical therapists, speech therapists, occupational therapists, and inhalation therapists. (2) Sitter service, private duty nursing service, medical social workers, and dietiti…

(1) Such items as are specified by Medicaid are available for use in the home. (2) See the chapter covering supplies, appliances, and durable medical equipment for further information. Author: Notes Ala. Admin. Code r. 560-X-12-.07 Rule effective October 1, 1982. Statutory Author…

(1) An eligible Medicaid recipient may be considered for home health services (i.e., nursing services and home health aide services) upon the initial written prescription or order signed and place by a physician licensed in the State of Alabama or an authorized non-physician prac…

(1) A visit is a personal contact in the place of residence of a patient made for the purpose of providing a covered service by a health worker on the staff of a certified Medicaid home health agency.(a) Home health care visits to Medicaid recipients must be medically necessary a…

(1) Persons eligible for Medicare and Medicaid are entitled to all services available under both programs, but a claim must be filed with Medicare if the services are covered by Medicare. A patient may not receive home visits under both programs simultaneously. If Medicare termin…

(1) The Home Health Agency agrees to accept as payment in full the amount paid for covered home health services, and cannot make any additional charges to the recipient, sponsor, or family of the recipient. (2) Medicaid recipients may be billed by providers for noncovered service…

(1) Durable Medical Equipment (DME), supplies, and appliances are available as Medicaid program benefits to eligible Medicaid beneficiaries for use in any setting in which normal life activities take place. (2) The covered DME, supplies, and appliances, and Prosthetics, Orthotics…

(1) Participating providers (also referred to as "all providers mentioned in this chapter" or "provider") are those Home Health Agencies, pharmacies, DME, supply, appliance and POP suppliers contracted with Medicaid for this program. (2) Participating providers must meet the Medi…

(1) A written order or a signed prescription (as defined by the Medicare Program Integrity Manual Chapter 5) signed by the prescriber is required for covered items. An EPSDT or Patient 1st primary physician (PMP) referral may be submitted as an order when written according to pra…

Notes Ala. Admin. Code r. 560-X-13-.04 Rule effective October 1, 1982. Amended: Effective November 11, 1985. Amended: Filed February 3,1997; effective March 10, 1997. Amended: Filed June 4, 1997; effective July 9, 1997. Amended: Filed October 12, 2001; effective November 16, 2001…

Notes Ala. Admin. Code r. 560-X-13-.05 Rule effective October 1, 1982. Amended: Effective August 9, 1984. Amended: Filed February 3, 1997; effective March 10, 1997. Amended: Filed June 4, 1997; effective July 9, 1997. Amended: Filed October 12, 2001; effective November 16, 2001. …

Notes Ala. Admin. Code r. 560-X-13-.06 Rule effective October 1, 1982. Amended: effective November 11, 1985; October 12, 1988; November 15, 1989; January 13, 1993. Amended: Filed February 3, 1997; effective March 10, 1997. Amended: Filed October 12, 2001; effective November 16, 2…

Non-covered items and services include, but are not limited to: (1) Items of a deluxe nature. (2) Replacement of usable equipment. (3) Items for use in hospitals, nursing homes, or other institutions. However, DME items may be provided in nursing homes or other institutions for c…

Notes Ala. Admin. Code r. 560-X-13-.08 Rule effective October 1, 1982. Amended: effective January 8, 1985; October 13, 1987. Emergency rule effective February 1, 1989. Amended: effective May 12, 1989. Reserved by Alabama Administrative Monthly Volume XXXIV, Issue No. 04, January …

Notes Ala. Admin. Code r. 560-X-13-.09 Rule effective October 1, 1982. Amended: Effective September 9, 1988. Reserved by Alabama Administrative Monthly Volume XXXIV, Issue No. 04, January 29, 2016, eff. 2/25/2016. Author: Theresa D. Richburg Statutory Authority: State Plan; 42 C.…

(1) Medicaid will reimburse for only those DME, supply, appliance or POP items indicated on the approval letter from Medicaid or its designee. (2) Reimbursement will be made for purchases or rentals in accordance with the DME Fee Schedule on the Medicaid website. (3) Request for …

(1) DME item(s) furnished by a supplier without receipt of an authorization to purchase by Medicaid will not be approved for reimbursement. (2) Item(s) supplied to an individual who is not eligible during the month in which the item(s) are furnished, are not reimbursable. (3) Med…

(1) Medicaid recipients are required to pay and suppliers are required to collect the designated co-pay amount for the rental or purchase of DME, supplies, appliances and POP, including crossover claims. (2) The co-payment fee does not apply to in certain situations in accordance…

Notes Ala. Admin. Code r. 560-X-13-.13 Emergency rule effective September 1, 1993. Effective date of this amendment December 14, 1993. Amended: Filed July 7, 1994; effective August 12, 1994. Amended: Filed August 11, 2004; effective September 15, 2004. Reserved by Alabama Adminis…

(1) Coverage is provided for Augmentative Communication Devices (ACD) for eligible individuals who meet criteria set out herein. Prior authorization for the ACD service is required. Requests for prior authorization must be made on the appropriate Alabama Prior Review and Authoriz…

(1) Oxygen Therapy is covered for the entire Medicaid population based on medical necessity and must be prior authorized by Medicaid. Requests for prior authorization must be made on the appropriate Alabama Prior Review and Authorization Request Form. The request must be accompan…

(1) External breast prostheses following mastectomy for breast cancer are covered for all Medicaid-eligible recipients meeting the criteria. Please refer to Chapter 14, DME, or the Medicaid Provider Manual published on Medicaid's website (2) Providers of external breast prosthese…

(1) Wheelchairs are a covered benefit for patients who meet full Medicaid eligibility criteria and medical necessity. The patient must meet criteria applicable to wheelchairs pursuant to this chapter, and Chapter 14, DME, of the Medicaid Provider Manual. (2) All requests for whee…

(1) Basic level prosthetics, orthotics and pedorthics are covered benefits to Medicaid eligible recipients up to age 65 in a non-institutional and institutional setting. The recipients must meet established Medicaid criteria applicable to prosthetic, orthotic, and pedorthic devic…

(1) All standard DME, appliances, and POP must have a warranty for a minimum of one year; this may include the manufacturer's warranty. If the provider supplies items that are not covered under a warranty, the provider is responsible for repairs, replacements and maintenance for …

Specific DME and POP coverage and policy not mentioned in this chapter are described in Chapter 14, DME, of the Medicaid Provider Manual, and is located on the Medicaid website. Questions related to specific coverage and policy should be submitted in writing or email to, Alabama …

(1) Family planning services are defined as the services provided to: (a) Prevent or delay pregnancy. (2) Family planning services are available through providers enrolled with the Alabama Medicaid Agency, including hospitals, primary care clinics, Rural Health Clinics, Federally…

(1) Eligible individuals are those females of childbearing age and males of any age, including minors who may be sexually active. (2) In determining recipient eligibility for family planning services, childbearing age is considered to be between 8 and 55 years of age. Notes Ala. …

(1) The following services are covered services when provided by Family Planning providers. Details on criteria required for each type of service is listed in the Family Planning Program Manual.(a) Initial Visit - an in-depth evaluation of a new patient requiring the establishmen…

Surgical procedures for male and female recipients as a method of birth control are covered services under the rules and regulations set forth below: (1) Rules and Regulations Concerning Federal Financial Participation for Sterilization, effective February 6, 1979, apply in the f…

(1) Medically necessary procedures for the treatment of illness or injury which would inevitably have a secondary effect of rendering an individual incapable of reproducing are not classified as family planning procedures. Claims for such procedures are payable based on determina…

(1) The Plan First Waiver program operates under an approved Section 1115(a) Research and Demonstration Waiver which includes Special Terms and Conditions. It extends Medicaid eligibility for family planning services to all females of childbearing age (19 through 55) and men (age…

(1) Chapter 560-X-1, General, contains references to the Code of Ala. 1975, regarding the rights of minors to consent to any legally authorized medical, dental, or other health services for himself or herself. (2) Illiterate recipients may give consent for family planning service…

(1) The co-payment on prescription drugs, and any indicated refills for Medicaid recipients does not apply to drugs and supplies designated as family planning items. (2) All medically approved family planning drugs and supplies are covered. Author: Dee Lockridge Notes Ala. Admin.…

(1) Refer to Chapter 1 of this Code for general information regarding providers billing Medicaid recipients. (2) Medicaid recipients are exempt from CO-payment requirements for family planning services. Author: Dee Lockridge Notes Ala. Admin. Code r. 560-X-14-.09 Rule effective A…

(1) The Medicaid fiscal agent will provide a report on sterilization claims adjudicated to be used for reporting expenditures to the Health Care Financing Administration. (2) The fiscal agent shall generate a report of Family Planning expenditures to be used for reporting expendi…

(1) A Family Planning Manual detailing the elements of each family planning visit, instructions for completion of forms, and procedures to follow in the administration of the local program are provided to each contracted provider. (2) Family planning providers will be required to…

(1) (a) The availability of certain dental health care services for eligible children under age 21 is required through the Alabama Medicaid Program as part of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program. (b) Certain dental services are provided to p…

A listing of the covered dental procedures and their limitations are included in the Alabama Medicaid Provider Manual, Chapter 13, which is provided by the fiscal agent. Author: Tina Edwards, Dental Program Notes Ala. Admin. Code r. 560-X-15-.02 Rule effective October 1, 1982. Em…

(1) Dental care is provided to Medicaid eligible individuals who are under age 21 and are eligible for treatment under the EPSDT Program. Complete details on coverage limitations are contained in Chapter 13 of the Alabama Medicaid Provider Manual. Below are general guidelines. (2…

(Repealed) Author: Notes Ala. Admin. Code r. 560-X-15-.04 Rule effective October 1, 1982. Emergency rule effective April 1, 1991. Amended effective June 12, 1991. Repealed: Filed September 6, 2000; effective October 11, 2000. Statutory Authority: State Plan; Title XIX, Social Sec…

(1) Certain services require prior authorization. Refer to Chapter 13 of the Alabama Medicaid Provider Manual. Author: Sharon Bean, Dental Program Notes Ala. Admin. Code r. 560-X-15-.05 Rule effective October 1, 1982. Amended effective May 9, 1984; January 8, 1985; August 9, 1985…

(1) Dental clinics administered by the Alabama Department of Public Health may participate in the program if they are approved by and enter into a vendor agreement (contract) with Medicaid. Providers who meet the Alabama Medicaid Agency enrollment requirements are eligible to par…

Under the provisions of Federal and State law, Medicaid must establish a mechanism to ensure that all such care is of good quality and that service(s) for which billing was made conforms to that which was done. See Chapter 2, Rule No. 560-X-2-.01(2)(d) and (3) for criteria. Autho…

(1) Fees submitted shall not exceed usual, customary, and reasonable rates paid by the non-Medicaid population of the community. (2) The provider shall not charge Medicaid for services rendered on a no-charge basis to the general public. (3) If the provider offers discounts or re…

(1) A mobile dental facility or portable dental operation (Mobile Dental Clinic) is any self-contained facility in which dentistry or dental hygiene is practiced which may be moved, towed, or transported from one location to another. (2) Mobile Dental Clinics shall comply with al…

(1) The State Plan provides for the payment of certain legend and non-legend drugs prescribed by Doctors of Medicine, and other practitioners including, but not limited to nurse practitioners, dentists and physician assistants who are legally authorized to prescribe these drugs a…