Alabama Administrative Code

Effective September 1, 1991, Return on Equity will no longer be used in rate computation. This does not relieve the provider of the responsibility of maintaining adequate records to account for receivables, prepaids, and payables. Notes Ala. Admin. Code r. 560-X-22-.16 Rule effec…

(1) The reasonable costs of funding "qualified" deferred compensation plans will be recognized as an allowable cost. "Qualified" deferred compensation plans means those plans which have been determined by the Internal Revenue Service to be qualified under Sections 401 or 405 of t…

(1) Allowable costs incurred by a provider for services or goods provided by related parties will not exceed the net cost of the services or goods to that related party, and that cost cannot exceed the fair market value of the items or services involved. (2) The provisions of HIM…

(1) Certain income items or receipts must be used to either offset costs or reduce total reported costs. Typical, but not all inclusive, examples of such transactions are: (a) Purchase discounts, rebates or allowances. (b) Recoveries or indemnities on losses (i.e., insurance proc…

(1) A chain organization consists of a group of two or more nursing facilities which are owned, leased, or through any other device controlled by related organizations or individuals. The home office of a chain organization is not a provider in itself; therefore, its costs may no…

(1) Multiple use facilities, such as hospital-nursing facilities or retirement home-nursing facilities, will allocate all allowable costs which are not directly associated with a specific revenue producing department. (2) Examples of costs which are usually allocated include, but…

(1) General: (a) All payments to providers for services rendered must be based on the reasonable cost of such services covered by the Alabama State Plan. It is the intent of the program that providers will be reimbursed the reasonable costs which must be incurred in providing qua…

(1) Extensions. Each provider is required to file a complete uniform cost report for each fiscal year ending June 30th. The complete uniform cost report must actually be received by Medicaid on or before September 15. Should September 15 fall on a state holiday or weekend, the co…

(1) The provider must submit adequate cost data based on financial and statistical records which can be verified by qualified auditors. The cost data must be presented on the accrual basis of accounting. This basis requires that revenue must be allocated to the accounting period …

(1) Personal Fund Management. In accordance with federal regulations for Medicare and Medicaid facilities, a medical assistance patient may manage his personal affairs unless a facility accepts the patient's delegation of this responsibility. A patient managing his personal affai…

(1) Audit adjustments will be paid or collected by a combination of (1) changing the per diem rate of the facility and (2) a lump sum settlement for the amount under/over paid for the period prior to the effective date of the per diem rate change. (2) Under/Overpayment situations…

(1) Facility administrators who disagree with the findings of the Medicaid desk audits or field audits may request, in writing, an informal conference at which they may present their positions. Such written requests must be received by Medicaid within thirty (30) days of the date…

(1) Whenever an overpayment of Medicaid reimbursement received by a provider from Medicaid results from the negligence or intentional disregard of Medicaid Reimbursement Principles by the provider or its representatives (but without intent to defraud), there will be deducted from…

(1) Cost Report Preparers. "Cost Report Preparer" includes any person (including a partnership or corporation) who, in return for compensation, prepares or employs another to prepare all or a substantial portion of a Medicaid cost report. A cost report preparer can include both t…

APPENDIX A FORMS 1. Patient Count and Analysis Sheet 2. Mileage Log 3. Final Audit Computation 4. Composite Estimated Useful Lives of Depreciable Hospital Assets Notes Ala. Admin. Code r. 560, ch. 560-X-22, 560-X-22-A

(1) This chapter of the Alabama Medicaid Administrative Code has been promulgated by the Alabama Medicaid Agency (Medicaid) as a guide for providers of Medicaid hospital care. This chapter is applicable to all hospitals participating in the Alabama Medicaid Program. Notes Ala. Ad…

(1) Access Payment: A payment by the Medicaid program to an eligible hospital for inpatient and outpatient hospital care provided to a Medicaid recipient. (2) Hospital: For purposes of Medicaid base, access and DSH payments for the period from October 1 through September 30 a fac…

(1) For the period October 1 through September 30 each hospital shall receive an inpatient Medicaid base (per diem) payment, in accordance with the following: (a) Medicaid shall pay a base (per diem) amount to each hospital from all sources except DSH payments as described in the…

(1) For the period October 1 through September 30, the amount available for inpatient hospital access payments shall be calculated as described in the Alabama Medicaid Agency State Plan and amendments thereto as currently approved by the Hospital Services and Reimbursement Panel.…

(1) For the period October 1 through September 30 in addition to any other funds paid to private free-standing psychiatric hospitals for inpatient hospital services to Medicaid patients, qualifying hospitals shall receive an annual private |free-standing psychiatric hospital acce…

(1) For the period from October 1 to September 30, qualified hospitals, in accordance with 42 CFR 433.51(b), will be paid a DSH payment as described in the Alabama Medicaid Agency State Plan and amendments thereto as currently approved by the Hospital Services and Reimbursement P…

(1) Payment for inpatient services provided by allout-of-state hospitals shall be calculated as described in the Alabama Medicaid Agency State Plan and amendments thereto as currently approved by the Hospital Services and Reimbursement Panel. Notes Ala. Admin. Code r. 560-X-23-.0…

(1) Certified emergency room visits must be properly documented by the attending licensed physician, nurse practitioner or physician assistant in the medical record. (2) Outpatient Medicaid Base Payments. Outpatient Medicaid Base Payments will be calculated as described in the Al…

(1) Day Outliers - The Alabama Medicaid Agency does not impose durational limits for medically necessary inpatient services provided to children under the age of 6 years in hospitals deemed by the Agency as disproportionate and under the age of 1 in all hospitals. Because we pay …

(1) The Alabama Medicaid Agency uses the electronic cost report (ECR) filing of the Form CMS-2552 Hospital and Hospital Health Care Complex Cost Report, as defined in CMS Provider Reimbursement Manual (PRM) 15-11 along with all accompanying schedules, forms and supporting informa…

(1) The total Medicaid cost per diems can be adjusted if the hospital experiences extraordinary circumstances which may include, but are not limited to, an Act of God, war, or civil disturbance. Adjustments to reimbursement rates may be made in these and related circumstances at …

Notes Ala. Admin. Code r. 560-X-23-.12 Rule effective June 9, 1986. Amended: effective May 25, 1988. Repealed: Filed November 10, 2010; effective December 15, 2010. (See history note at end of chapter.) Author: Susan Mims Statutory Authority: State Plan, Title XIX, Social Securit…

Notes Ala. Admin. Code r. 560-X-23-.13 Rule effective June 9, 1986. Amended: effective August 10, 1987. Emergency rule effective October 1, 1991. Amended: effective January 14, 1992. Amended: effective May 11, 1993. Repealed: Filed November 10, 2010; effective December 15, 2010. …

Notes Ala. Admin. Code r. 560-X-23-.14 Rule effective June 9, 1986.) Amended: effective May 11, 1993. Amended: Filed July 7, 1994; effective August 12, 1994. Repealed: Filed November 10, 2010; effective December 15, 2010. (See history note at end of chapter. Author: Statutory Aut…

Notes Ala. Admin. Code r. 560-X-23-.15 Rule effective June 9, 1986. Amended: effective September 9, 1987; December 10, 1987. Amended: effective July 13, 1989; July 19, 1990. Amended: effective May 11, 1993 Repealed: Filed November 10, 2010; effective December 15, 2010. (See histo…

Notes Ala. Admin. Code r. 560-X-23-.16 Emergency rule effective June 9, 1986. Permanent rule effective June 9, 1986. Amended: effective September 8, 1986; October 11, 1986; December 10, 1987; May 25, 1988. Amended: Effective November 10, 1988; April 14, 1989. Emergency rules effe…

Notes Ala. Admin. Code r. 560-X-23-.17 Rule effective June 9, 1986. Repealed: Filed November 10, 2010; effective December 15, 2010. (See history note at end of chapter.) Rule was renumbered to .07 as per certification filed November 10, 2010; effective December 15, 2010. Author: …

Notes Ala. Admin. Code r. 560-X-23-.18 Rule effective June 9, 1986. Amended: effective December 10, 1987. Amended: effective May 11, 1993. Repealed: Filed November 10, 2010; effective December 15, 2010. (See history note at end of chapter.) Author: Susan Mims Statutory Authority:…

Notes Ala. Admin. Code r. 560-X-23-.19 Rule effective June 9, 1986. Amended: effective May 11, 1993. Repealed: Filed November 10, 2010; effective December 15, 2010. (See history note at end of chapter.) Author: Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C…

Notes Ala. Admin. Code r. 560-X-23-.20 Emergency rule effective June 9, 1986. Permanent rule effective June 9, 1986. Amended: effective September 8, 1986; June 10, 1987. Repealed: Filed November 10, 2010; effective December 15, 2010. (See history note at end of chapter.) Rule was…

Notes Ala. Admin. Code r. 560-X-23-.21 Rule effective June 9, 1986. Amended: effective September 9, 1987. Repealed: Filed November 10, 2010; effective December 15, 2010. Original Chapter 560-X-23 (Rules 560-X-23-.01 through 560-X-23-.08) effective September 30, 1982. Repealed and…

End Stage Renal Disease (ESRD) services are outpatient maintenance services, which may be provided by a freestanding ESRD facility or a renal dialysis center. Author: Notes Ala. Admin. Code r. 560-X-24-.01 Rule effective October 1, 1982. Amended: Effective January 14, 1987. Statu…

(1) In order to participate in the Title XIX Medicaid Program and to receive Medicaid payment for services, ESRD facilities/centers must meet all the following requirements: (a) Certification for participation in the Title XVIII Medicare Program; (b) Approval by the appropriate l…

(1) Maintenance dialysis treatments are covered when they are provided by a Medicaid enrolled ESRD hospital-based renal dialysis center or freestanding ESRD facility. The most common elements of a dialysis treatment are overhead costs, personnel services (administrative services,…

Laboratory tests listed below are considered routine and are included as part of the composite rate of reimbursement. All other medically necessary lab tests are considered nonroutine and must be billed directly by the actual provider of service. (a) Hemodialysis 1. Per treatment…

(1) Medically necessary take-home drugs must be billed under the pharmacy program by the actual provider of services. (2) Routine parenteral items are included in the facility composite rate and may not be billed separately. (3) Nonroutine injectables administered by the facility…

Author: Luann C. McQueen Authority: State Plan; Title XIX, Social Security Act; Alabama Medicaid Agency Administrative Code, Rule 560-X-1-.15. Notes Ala. Admin. Code r. 560-X-24-.06 Rule effective October 1, 1982. Amended: Effective January 14, 1987. Repealed: Effective October 1…

(1) All physician services rendered to each outpatient maintenance dialysis patient (regardless of the patient's mode of or setting for dialysis) shall be billed on a monthly capitation basis. (2) Services not covered by the monthly capitation payment (MCP) and which are reimburs…

Payment for renal dialysis crossover claims shall be made on the basis of a ratio of costs to charges as developed by Medicaid. Author: Notes Ala. Admin. Code r. 560-X-24-.08 Rule effective October 1, 1982. Amended: Effective January 14, 1987. Statutory Authority: State Plan; Tit…

(1) No eligible Alabama Medicaid recipient is to receive a bill or statement for covered services or items, once that recipient has been accepted as a Medicaid patient. (2) The provider may send a notice to the recipient stating their claim is still outstanding, provided the noti…

(1) In determining eligibility for Medicaid, the Agency's rules and regulations are governed by the Social Security Act (hereinafter referred to as the Act), Titles XVI and XIX; 20 C.F.R. (Part 416); 42 C.F.R. (Part 435); and the Alabama State Plan for Medical Assistance. (2) Any…

(1) The Alabama Medicaid Agency determines eligibility for individuals for the following programs: (a) All Medicaid programs in accordance with Titles XIX and XXI of the Act except those listed in (2) and (3) below; and, (b) Low Income Subsidy (LIS) under Medicare Part D in accor…

(1) The following are the general groups of individuals designated as categorically eligible under the State Plan for Medical Assistance, and who as a result are Medicaid eligible:(a) Aged, blind or disabled persons who receive Supplemental Security Income (SSI) under Title XVI; …

(1) An application is a specific written request on the designated agency application form which has been completed, dated and signed (including State acceptable electronic signatures) by the applicant and/or applicant's representative or guardian to have eligibility for categori…

(1) In order to qualify for Medicaid, AFDC-related and MAGI-related individuals must meet the nonfinancial eligibility criteria of the AFDC programs. (2) SSI - related individuals must meet general categorical criteria of age, disability or blindness, residence, and citizenship f…