Alabama Administrative Code

(1) To be eligible for participation in the Alabama Medicaid Ambulance Program and to receive payment for service, each provider of ambulance service in Alabama in compliance with Rule No. 560-X-18-.02(2) must enter into a written agreement with Alabama Medicaid Agency. (2) Ambul…

(1) Act No. 645 passed by the 1976 Regular Session of the Legislature of Alabama provided that any person who, with intent to defraud or deceive, makes or causes to be made, any false statement or representation of material fact in any claim or application for any payment, regard…

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 the service(s) for which billing was made, conforms to that which was done. See Chapter 2, Rule 560-X-2-.01(2) and (3) for criteria. R. Dale…

(1) Covered Services (a) Air transportation services are covered for adults and children with authorization required prior to payment. Air transportation may be rendered only when basic and advanced life support land ambulance services are not appropriate. Medical appropriateness…

(1) As the State Agency for administering the Non-Emergency Transportation Program, under Title XIX of the Social Security Act, the Alabama Medicaid Agency must ensure that transportation for Medicaid allowable medical services is available for all eligible recipients in the stat…

(1) Eligible recipients must receive the least expensive appropriate transportation that does not endanger their health, to facilities that are accessible and appropriate for Medicaid covered medical services for which a recipient has available benefits. (2) Recipients who reques…

(1) Reimbursement for transportation services is furnished through an Electronic Benefit Transfer System (EBT) process wherein the recipient uses the reimbursement to purchase transportation. Non-emergency ambulance transportation is reimbursed fee for service. (2) A tiered fee f…

(1) The Alabama Medicaid Agency staff, including Regional NET Coordinators and Central Office staff, serve as the point of contact and assist with scheduling the least expensive appropriate NET on a statewide basis. Recipients must contact the Agency to request transportation ass…

(1) An escort is defined as an individual, other than an employee of a Transporter, whose presence is required to assist a recipient during transport and while at the place of treatment. An escort is typically a relative, guardian, or volunteer. Only one escort is covered per rec…

(1) NET reimbursements will be issued for transportation costs to and from covered necessary medical services for which the recipient has benefits available as defined at 42 CFR 440.210 including Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), inpatient hospital s…

(1) Net services may be provided by one or more of the modes listed below when the recipient's medical care is necessary and the recipient has no other transportation resources. The least costly mode of transportation appropriate to the needs of the recipient must be used. This s…

(1) A maximum of one round trip may be reimbursed per date of service per recipient, without prior authorization exception. Notes Ala. Admin. Code r. 560-X-18-.23 New Rule: Filed February 7, 1996; effective March 14, 1996. Amended: Filed August 11, 2010; effective September 15, 2…

(1) When appropriate free transportation is available. (2) any travel when the Medicaid recipient is not an occupant of the vehicle unless that would be the most economical transportation available; (3) meals and lodging for volunteer drivers; (4) the use of supplies such as oxyg…

The Medicaid Coverage of Certain Medical Transportation under the Consolidated Appropriations Act, 2021 (Public Law 116-260) established provider and driver minimum requirements for participation in NET, excluding any public transit authority. Provider(s) and driver(s) must adher…

(1) Audiological function tests and hearing aids are limited to Medicaid eligible individuals who are eligible for treatment under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program. Hearing aids are provided through hearing aid dealers who are contracted t…

(1) Only in-state and borderline out-of-state (within 30-mile radius of state line) audiology and hearing aid providers who meet enrollment requirements are eligible to participate in the Alabama Medicaid program. Audiology providers: Must hold a valid current state license issue…

(1) Audiologists and hearing aid dealers should refer to Rule 560-X-1-.17, Chapter one, Administrative Code, for provider billing instructions. (2) Claim forms and billing instructions will be furnished to participating providers by Medicaid's fiscal agent. (3) An audiologist emp…

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…

(1) General. (a) The purpose of the Third Party Division of Alabama Medicaid Agency is to fulfill the requirements pertaining to third party liability and to ensure that Medicaid is the payer of last resort. (b) In general third party resources are primary to Medicaid. (c) Federa…

(1) General. (a) All providers must file claims with a third party as specified by this rule. (b) Providers should not file with Medicaid until the third party responds with a payment or denial. Exceptions: Providers may file Medicaid and Medicare simultaneously if the Medicare i…

(1) The Claim - All providers are required to question Medicaid recipients to obtain information about third party resources which may pay for medical services provided to the recipient. All providers must complete third party fields on the Medicaid claim as required in the Alaba…

(1) Third Party Payments other than Medicare (a) Third Party payments must be applied to the services for which the third party paid. (b) Providers receiving a third party payment prior to filing Medicaid must document in the appropriate field on the claim the amount of the third…

(1) Requests for copies of recipient's medical bills, histories, and statements provide Medicaid with third party resource leads. Therefore, information that is released by providers and that pertains to the care and treatment of a Medicaid recipient must be documented and report…

(1) Medicaid's fiscal agent is responsible for monitoring all claims for possible third party liability and utilizing information on the claim to identify potential Third Party liability. The fiscal agent will utilize Medicare coverage dates, the Commercial TPL policy file and Me…

(1) The Alabama Medicaid Agency by statute is subrogated to the rights of a Medicaid recipient against any third party arising out of injury, disease, or sickness. Medicaid recipients are required to assist and cooperate fully with Alabama Medicaid Agency in its efforts to secure…

(1) The Alabama Medicaid Agency may pay health insurance premiums of certain Medicaid eligibles or recipients when the agency determines that payment of the premium would be cost effective. The primary objective of paying certain health insurance premiums is to reduce Medicaid ex…

(1) Alabama Law provides rules under which properly trained nurses can be licensed to practice the profession of Nurse Midwifery. (Code of Ala. 1975, §§ 34-19-2, et seq.) (2) Federal Law [Title XIX, Sections 1905(a)(17) and (m)] requires that the Medicaid Program in each state in…

(1) Providers in this program are limited to persons who are licensed as "Registered Nurse" and who are also licensed as "Certified Nurse Midwife." (2) Nurse Midwifery practice is defined as the management of care for normal healthy women and their babies in the areas of prenatal…

(1) In order to participate in the program a nurse midwife must submit a completed application form along with a copy of current registered nurse and nurse midwife licensure, plus copy of the written signed agreement between the nurse midwife and the physician consultant. If the …

(1) Nurse midwives may submit claims and be reimbursed only for those procedure codes authorized by Medicaid policy. Claims should be submitted on a Health Insurance (HCFA 1500) Claim Form. (2) The nurse midwife agrees when billing Medicaid for a service that the midwife will acc…

(1) The maternity services normally provided in maternity cases include antepartum care, delivery, and postpartum care. When a nurse midwife provides total obstetrical care, the procedure code which shall be filed on the claim form is the code for all inclusive "global" care. The…

(1) When a patient is accepted for monthly services, the midwife's care must include plans for a delivery to be accomplished in a licensed hospital. In an emergency, delivery may be accomplished elsewhere. The plans need not be submitted to Medicaid but the midwife's file should …

(1) The supervising physician may not bill for supervisory services. The physician can bill Medicaid, however, if it becomes necessary for the physician to perform the delivery or complete a delivery service for the nurse midwife. When the physician bills the delivery only servic…

(1) Nurse Midwives are required to identify recipients who are covered by third party resources and to obtain payment from those resources in accordance with Chapter 20 of the Medicaid Agency's Administrative Code. Author: Notes Ala. Admin. Code r. 560-X-21-.08 Effective date of …

(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 maternity care and family planning services. (3) Co-pay requirements apply to well-woman gynecological …

This regulation states the Medicaid policy regarding nursing facility reimbursement and establishes the accepted procedures whereby reimbursement is made to nursing facility providers. Because of the length and complexity of this chapter, it has been divided into the following se…

(1) This chapter of the Alabama Medicaid Regulations has been promulgated by the Alabama Medicaid Agency, Medicaid, for the guidance of providers of Medicaid nursing facility care. This chapter is applicable to those providers categorized as NF, NF/IMD, and NF/IDD. It does not ap…

(1) Accrual Method of Accounting - Revenues must be allocated to the accounting period in which they are earned and expenses must be charged to the period in which they are incurred. This must be done regardless of when cash is received or disbursed. (2) Adjusted Reported Costs -…

Mandated Continuing Education Units for nurses and inservice training for nurse aides will be an allowable cost in the direct cost center if it was received in the State of Alabama. All other education cost will be accounted for in the operating cost center. Author: Bob Murphy No…

(1) The Medicaid per diem rate will be determined under reimbursement methodology contained in this chapter. (See Rule 560-X-22-.06.) The rates will be based on the cost data contained in cost reports (normally covering the period July 1 through June 30th). In order to allow adeq…

(1) All nursing facilities will be grouped into three (3) functional categories: (a) Nursing Facility (NF). (b) Nursing Facility/Institution for Mental Disease (NF/IMD). (c) Nursing Facility/Institution for the Developmentally Disabled (NF/IDD). (2) The following methodology shal…

(1) The Medicaid Inflation Index will be used in lieu of budgeting to adjust certain actual allowable costs from one reporting period for the purpose of computing the per diem rate payable for a subsequent reporting period and for such other adjustments as may be specified in thi…

(1) A patient day is incurred when any one of the following conditions have been met: (a) Care is rendered to a patient in the facility. This results when a patient is rendered services between the census taking hour (12:00 midnight) on two (2) successive days. The following proc…

(1) Providers are expected to staff nursing care functions in accordance with state licensure requirements. (2) Staffing of each functional area within each facility will be reviewed by Medicaid for reasonableness. (3) An adjustment will be made to decrease allowable costs for fa…

(1) Costs of a management or administrative nature, including but not limited to those costs outlined in Rule 560-X-22-.10(3), will be reported as such on the Medicaid Cost Report. Salaries of administrative personnel which would duplicate employee salary expenses in other cost c…

(1) Necessary and reasonable interest expense is an allowable cost. In order to be considered necessary, the interest must be incurred on a loan made to satisfy a financial need directly related to patient care. Loans which result in excess funds or which are not related to patie…

(1) Allowable costs will be limited to the laundry costs which are ordinary and necessary to the operation of a nursing facility and will not include costs associated with the personal laundry of patients. (2) Examples of such costs include, but are not limited to, the following:…

(1) Travel that is necessary and that is directly related to the operation of the nursing facility claiming reimbursement for the expense will be an allowable cost for reimbursement purposes pursuant to the following specific provisions: (a) Automobile: 1. Since the form of vehic…

(1) In order for any property costs to be reimbursed through the Medicaid program, capital expenditures must be approved under applicable Certificate of Need regulations by appropriate state and/or federal agencies. Capital expenditures, as used in this chapter, means new constru…

(1) A provider who constructs, leases, or purchases a facility, or has a change in category of care, can request reimbursement based on an operating budget, subject to the ceiling established under Rule 560-X-2-.05 of this chapter. In this event, the facility will be subject to a…