Alabama Administrative Code

Notes Ala. Admin. Code r. 560-X-35-.06 Rule effective July 9, 1985. Amended: effective November 18, 1987, November 10, 1988, June 6, 1990. Amended: Filed December 9, 1996; effective January 14, 1997. Amended: Filed December 10, 2004; effective January 14, 2005. Amended: Filed Mar…

(1) Alabama Medicaid Agency will require an individual plan of care for each wavered service recipient. Such plan, entitled "Individual Habilitation Plan" (IHP), is subject to review by the Alabama Medicaid Agency and Department of Health and Human Services. Client assessment pro…

(1) Alabama Medicaid Agency will be responsible for assurances that beneficiaries of the waiver service program will be advised of the feasible service alternatives and be given a choice of which type of service--institutional or home- and/or community-based services--they wish t…

(1) The Medicaid reimbursement for each service provided by a mental health service provider shall be based on a fee-for-service system. Each covered service is identified on a claim by a procedure code. (2) Providers should bill no more than one month's services on a claim for a…

Providers shall make all reasonable efforts to determine if there is a liable third party source, including Medicare, and in the case of a liable third party source, utilize that source for payments and benefits prior to applying for Medicaid payments. Third party payments receiv…

(1) Payment made by the Medicaid Program to a provider shall be considered to be payment in full for covered services rendered. (2) No Medicaid recipient shall be billed for covered Medicaid services for which Medicaid has been billed. (3) No person or entity, except a liable thi…

Providers shall not use or disclose, except to duly authorized representatives of federal or state agencies, any information concerning an eligible recipient except upon the written consent of the recipient, his/her attorney, or his/her guardian, or upon subpoena from a court of …

(1) The Department of Mental Health shall make available to the Alabama Medicaid Agency at no charge, all information regarding claims submitted and paid for services provided eligible recipients and shall permit access to all records and facilities for the purpose of claims audi…

The Home and Community-Based ID Waiver is a cooperative effort between the Alabama Medicaid Agency and the Department of Mental Health. Notes Ala. Admin. Code r. 560-X-35-.14 New Rule: Filed December 9, 1996; effective January 14, 1997. Amended: Filed October 21, 2004; effective …

(1) The Alabama Medicaid Agency will provide the operating agency with the approved level of care determination process. (2) The operating agency will review the applicant's eligibility status to determine if the applicant is medically and financially eligible for waiver services…

The cost for services to individuals who qualify for Home and Community-Based care under the waiver program will not exceed on an average per capita basis the total expenditures that would be incurred for such individuals if Home and Community-Based services were not available. N…

(1) An individual receiving a Notice of Action (denial, termination, suspension, reduction in services) from the operating agency (OA), may request an appeal if he/she disagrees with the decision. The Notice of Action explains the reason for the denial, termination, suspension, o…

Notes Ala. Admin. Code r. 560-X-35-.18 New Rule: Filed December 9, 1996; effective January 14, 1997. Amended: Filed December 10, 2004; effective January 14, 2005. Repealed: Filed March 13, 2009; effective April 17, 2009. Author: Laura Walcott, Administrator, LTC Program Managemen…

(1) Home-and community-based services to the elderly and disabled are provided by the Alabama Medicaid Agency to categorically needy individuals who would otherwise require institutionalization in a nursing facility. These services are provided through a Medicaid waiver under the…

(1) Financial eligibility is limited to those individuals receiving SSI, individuals deemed to be receiving SSI, the optional categorically needy at a special income level of 300 percent of the Federal Benefit Rate (FBR) who are receiving HCBS waiver services, individuals receivi…

The Home- and Community-Based Waiver for the Elderly and Disabled is a cooperative effort among the Alabama Medicaid Agency, and the Alabama Department of Senior Services. The State affirms that it will abide by all terms and conditions set forth in the waiver. Notes Ala. Admin. …

(1) Case Management Services.(a) Case management is a system under which responsibility for locating, coordinating, and monitoring a group of services rests with a designated person or organization. A case manager is responsible for outreach, intake and referral, diagnosis and ev…

The costs for services to individuals who qualify for home- and community-based care under the waiver program will not exceed, on an average per capita basis, the total expenditures that would be incurred for such individuals if home- and community-based services were not availab…

(1) The case manager will receive referrals from hospital, nursing homes, physicians, the community and others for persons who may be eligible for home- and community-based services. For institutional residents residing in a facility for at least 90 days who are interested in tra…

(1) The financial accountability of providers for funds expended on home- and community-based services must be maintained and provide a clearly defined audit trail. Providers must retain records that fully disclose the extent and cost of services provided to eligible recipients f…

(1) An individual whose application to the waiver program is denied or waiver participants whose services are terminated, suspended, or reduced based on Rule No. 560-X-36-.02, may request an appeal in accordance with 42 CFR Section 431, Subpart E and Chapter 3 of the Alabama Medi…

(1) Medical pays providers the actual cost to provide the service. Each covered service is identified on a claim by a HCPC code. Respite care will have one code for skilled and another for unskilled. Home delivered meals will also have one code and two modifiers. Frozen meals and…

Providers shall not use or disclose, except to duly authorized representatives of federal or state agencies, any information concerning an eligible recipient except upon the written consent of the recipient, his or her attorney, and/or guardian, or upon subpoena from a court of a…

(1) Fiscal audits of the Elderly and Disabled Waiver Services are conducted by the Provider Audit Division of Medicaid. At the completion of the field audit there will be an exit conference with the operating agency to explain the audit findings. The operating agency will have th…

The Third Party Division, Alabama Medicaid Agency, is responsible for fulfilling the requirements pertaining to third party liability. The purpose of the Third Party Division is to ensure that Medicaid is the payor of the last resort. Providers shall make all reasonable efforts t…

(1) The Medicaid Agency may, at its discretion, and in consultation with local communities, organize and develop area specific systems as part of an overall managed care system. (a) Flexibility. Since community needs and resources differ from area to area, the Medicaid Agency wil…

(1) Under this model of managed care, each patient/recipient is assigned to a primary medical provider (PMP) who is a physician who is responsible for managing the recipient's health care needs. This management function neither reduces nor expands the scope of covered services.(a…

(1) A prepaid inpatient health plan (PIHP) is one that provides services to enrolled recipients on a capitated basis but does not qualify as a HMO. (2) Capitated PIHPs do not need to meet the requirements of §1903(m)(2)(A) of the Social Security Act if services are less than full…

(1) Health Maintenance Organizations (HMO) means any entity or corporation that undertakes to provide or arrange for basic health care services through an organized system which combines the delivery and financing of health care to enrollees. The organization shall provide physic…

(1) A Medicare Health Maintenance Organizations (MHMO) and Competitive Medical Plans (CMP) are organizations which may contract with the Health Care Financing Administration (HCFA) to enroll Medicare beneficiaries and other individuals and groups to deliver a specified comprehens…

Notes Ala. Admin. Code r. 560-X-37-.06 New Emergency Rule: Filed August 28, 2000; effective October 1, 2000. New Rule: Filed September 21, 2000; effective December 11, 2000. Amended: Filed November 8, 2001; effective December 13, 2001. Repealed (Moved to 560-X-14-.06) : Filed Dec…

The Alabama Medicaid Agency is responsible for the development and oversight of the Alabama Coordinated Health Network (ACHN) program which provides case management programs in order to provide seamless care coordination that focuses on quality and improved health outcomes. The A…

(1) Bases for Imposition of Sanctions on Alabama Coordinated Health Network Entity. The Medicaid Agency may impose sanctions on an Alabama Coordinated Health Network Entity ("Entity") if the Medicaid Agency determines in its sole discretion that the Entity has violated any applic…

(1) Under the Alabama Coordinated Health Network (ACHN) Program, Medicaid recipients will be attributed to Primary Care Physician (PCP) Groups based on the historical visitation practices of the Medicaid recipient. Attribution is the process that will be used to associate a Medic…

(1) Primary Care Physician (PCP) Groups. (a) To participate with an Alabama Coordinated Health Network (ACHN), a PCP Group must engage with the ACHN as follows:1. PCP Groups must sign two agreements beyond their Medicaid enrollment: (i) A PCP Group Agreement with Alabama Medicaid…

(1) Ambulatory surgical services are those procedures typically performed on an inpatient basis which call be performed safely on an outpatient or ambulatory surgical center (ASC) basis. (2) Ambulatory surgical center services shall be reimbursed by means of a predetermined fee e…

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

(1) Payment shall be made for a surgical procedure performed on a Medicaid recipient only if the procedure is on the approved list. (2) Ambulatory surgical center services are items and services furnished by an outpatient ambulatory surgery center in connection with a covered sur…

(1) Covered surgical procedures are those procedures that meet the following standards: (a) Those surgical procedures which are commonly performed on an inpatient basis in hospitals, but may be safely performed in an ambulatory surgical center setting; (b) Those surgical procedur…

The ambulatory surgical centers shall have an effective procedure for the immediate transfer to a hospital of patients requiring emergency medical care beyond the capabilities of the center. The hospital shall have a provider contract with the Alabama Medicaid Agency. The center …

The surgical procedures shall be classified into separate payment groups. All procedures within the same payment group are reimbursed at a single rate. These rates are subject to adjustment by the Alabama Medicaid Agency. The group payment amount is lowest for Group One procedure…

(1) Ambulatory surgical center services are treated as medical services. UB82 claim forms shall be submitted for payment listing facility provider number, HCFA Common Procedure Coding System (HCPCS) and ICD-9-CM diagnosis codes (dates services prior and up to September 30, 2015) …

Refer to Chapter One of the Alabama Medicaid Administrative Code, Rule 560-X-1-.18(5)(a), as amended. Author: Notes Ala. Admin. Code r. 560-X-38-.08 Rule effective September 1, 1986. Statutory Authority: State Plan; Title XIX, Social Security Act; Alabama Medicaid Agency Administ…

(1) No eligible Alabama Medicaid recipient shall receive a bill or statement for covered services or items once the recipient has been accepted as a Medicaid patient. A recipient may be billed by the provider for noncovered services or items. (2) The provider may send a notice to…

(1) Medicaid recipients are required to pay, and ambulatory surgery center providers are required to collect, the designated copayment amount for each visit. Refer to Rule 560-X-1-.25 General Chapter for copay information. (2) A provider may not deny services to any eligible indi…

(1) ESWL is a covered benefit for treatment of kidney stones in the renal pelvis, uretero-pelvic junction, and the upper one-third of the ureter. (2) ESWL is not a covered service for urinary stones of the bladder and the lower two-thirds of the ureter. Authors: Charles A. Reasne…

(1) In order for the Alabama Medicaid Agency to reimburse the facility for ESWL treatment, the facility must have a signed ESWL Contract with the Agency. (2) For ESWL treatment to both kidneys during the same treatment period, Medicaid will pay the facility one-and-a-half times t…

(1) For ESWL treatment to both kidneys during the same treatment period, Medicaid will pay the surgeon one-and-a-half times the regular reimbursement rate for the surgical procedure. (2) For repeat ESWL treatments on the same recipient within a ninety-day period, Medicaid will re…

Anesthesiologist services are not included in the facility's or physician's reimbursement rate and therefore can be billed separately. Author: Charles A. Reasner Notes Ala. Admin. Code r. 560-X-39-.04 Rule effective October 13, 1987. Statutory Authority: State Plan; Title XIX, So…

(In order to participate in the Title XIX Medicaid Program as an ESWL provider, the following requirements must be met: (a) Submit written request for enrollment (b) Submit documentation that the lithotripsy machine is FDA approved (c) Provide documentation to indicate the lithot…