Alabama Administrative Code

(1) The Program Integrity Division is responsible for planning, developing, and directing Agency efforts to identify, prevent, and prosecute fraud, waste and/or abuse in the Medicaid Program. This includes verifying that medical services are appropriate and rendered as billed, th…

The purpose of the Program Integrity Division is: (1) To guard against fraud, waste, and/or abuse of Medicaid program benefits by individual providers and recipients; (2) To assure that Medicaid recipients receive necessary medical care at a level of quality consistent with that …

(1) Acquire, organize, and analyze data. (2) Present computer results through special reports that will enable Program Integrity to accomplish the following:(a) Develop a comprehensive statistical profile of health care delivery and utilization patterns. (b) Reveal suspected inst…

(1) Fraud is defined as an intentional deception or intentional misrepresentation made by a person with the knowledge that the deception could result in some unauthorized personal benefit or unauthorized benefit to some other person. Fraud is dependent upon evidence that must sub…

(1) Recipient fraud, waste, and abuse cases include, but are not limited to, the following categories: (a) Drug overutilization or overutilization of services; (b) Sale, alteration, or lending of the Medicaid card to others for services; (c) Criminal activity involved in securing…

The Alabama Medicaid Agency Quality Control Unit is responsible for monitoring Medicaid eligibility correctness. Through its findings administrators may identify and eliminate or reduce dollar losses by effective corrective action in program operations. (1) Quality Control shall …

(1) Optional Targeted Case Management (TCM) Services - those services to mentally ill adults (Target Group 1), intellectually disabled adults (Target Group 2), disabled children (Target Group 3), foster children (Target Group 4), pregnant women (Target Group 5), AIDS/HIV-positive…

(1) Providers of case management services must meet the following requirements: (a) CMSP for the mentally ill must be certified by the Department of Mental Health as meeting the qualifications for enrollment as a case management provider under the provision of 560-X-40-.01(6); (b…

(1) Reimbursement is made only for services rendered pursuant to mentally ill adults, intellectually disabled adults, disabled children, foster children, pregnant women, AIDS/HIV-positive individuals, adult protective service individuals, individuals who meet the eligibility crit…

(1) Governmental providers will be paid on a negotiated rate basis which will not exceed actual costs and which will meet all requirements of OMB Circular A-87. Nongovernmental providers will be reimbursed on a negotiated rate basis which will not exceed the upper limitations of …

The CMSP 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 filing a Medicaid claim. Third party payments received after…

(1) Payment made by the Alabama Medicaid Program to a CMSP shall be considered payment in full for covered services rendered. (2) No Medicaid recipient shall be billed for covered Medicaid services. (3) No person or entity, except a potential third party source, shall be billed f…

The CMSP 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 attorney, or his guardian, or upon subpoena from a court of appropri…

(1) The CMSP shall make available to the Alabama Medicaid Agency at no charge, all information describing services provided to eligible recipients and shall permit access to all records and facilities for the purpose of claims audit, program monitoring, and utilization review by …

(1) Inpatient psychiatric services for recipients under age 21 are covered services when provided: (a) Under the direction of a physician, (b) By a psychiatric hospital enrolled as a Medicaid provider in accordance with Rule No. 560-X-41-.02; OR (c) By a psychiatric residential t…

(1) Hospitals: (a) In order to participate in the Title XIX Medicaid program and to receive Medicaid payment for inpatient psychiatric services for individuals under age 21, a provider must meet the following conditions: 1. Be certified for participation in the Medicare/Medicaid …

(1) For purposes of this chapter, an inpatient is a person who has been admitted to a psychiatric facility for bed occupancy for purposes of receiving inpatient psychiatric services. (2) The number of days of care charged to a recipient for inpatient psychiatric services is alway…

(1) Certification of need for inpatient hospital services is a determination which is made by the certifying team as specified in (4) below regarding the Medicaid recipient's treatment needs for admission to the facility. (2) The appropriate team must certify that: (a) Ambulatory…

(1) Before admission to a psychiatric facility or before authorization for payment, the attending physician or staff physician must make a medical evaluation of each recipient's need for care in the facility and appropriate professional personnel must make a psychiatric and socia…

(1) Inpatient psychiatric services are covered by Medicaid only if they involve active treatment which means implementation of a professionally developed and supervised individual plan of care that is: (a) Developed and implemented no later than 14 working days after admission, a…

As a condition of participation in the Title XIX Medicaid program, each psychiatric facility shall: (a) Have in effect a written UR plan that provides for review of each recipient's need for services that the facility furnishes to him. This written UR plan must meet the requireme…

(1) Payment for inpatient services provided by psychiatric hospitals shall be the per diem rate established by Medicaid for the hospital which is based on the Medicaid cost report and provisions of Chapter 23 of the Alabama Medicaid Administrative Code. (2) Providers are required…

(1) All patients seeking admission to a psychiatric hospital must require psychiatric services that can only be provided on an inpatient basis. These psychiatric services must involve implementation of a professionally developed and supervised individualized plan of care. (2) The…

(1) The determination of the level of care will be made by a licensed nurse of the hospital staff. (2) Five percent of all admissions and concurrent stay charts will be retrospectively reviewed by the Medicaid Agency or designee on a monthly basis. (4) For an individual who is a …

(1) The provider's interdisciplinary treatment team is responsible for performing continued stay reviews on recipients who require continued inpatient hospitalization. These continued stay review dates will be determined by the PA Unit following an evaluation of the information s…

(1) Recertification of need for inpatient care must be made on the PSY-3 form at least every 60 days after admission by the patient's attending physician and filed in the patient's medical record. Author: Lynn Sharp, Associate Director, Policy Development Unit Notes Ala. Admin. C…

(1) Recipients seeking admission to a psychiatric residential treatment facility (PRTF) shall require continuous and active psychiatric treatment and care in a facility which meets the standards in 560-X-41-.02(2) (a-b). (2) Recipients seeking admission to a PRTF must meet at lea…

(1) The PRTFs interdisciplinary team shall be responsible for performing continued stay reviews on recipients who require continuous residential services. (2) Recipients requiring continued stays in PRTFs must meet at least one of the criteria listed in 560-X-41-.09(4) (a-f). (3)…

Recertification of need for residential services shall be noted on the recipient's plan of care by the attending physician at least every 30 days. Author: Lynn Sharp, Associate Director, Institutional Services Notes Ala. Admin. Code r. 560-X-41-.15 New Rule: Filed November 8, 200…

(1) PRTFs seeking enrollment with Medicaid must meet the requirements of 42 CFR, Part 483, Subpart G, regarding the reporting of serious occurrences. (2) PRTFs shall submit a written attestation of compliance with the federal rules at the time of enrollment. The written attestati…

This regulation states the Medicaid policy regarding ICF/IID reimbursement and establishes the accepted procedures whereby reimbursement is made to these providers. Because of the length and complexity of this Chapter, it has been divided into the above sections to facilitate its…

(1) This Chapter of the Alabama Medicaid Regulations has been promulgated by the Alabama Medicaid Agency (Medicaid) for the guidance of providers of Medicaid ICF/IID care. This Chapter is applicable to those providers classified as ICF/IID. (2) The Alabama Medicaid Program is adm…

(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) Cash Basis of Accounting …

(1) All ICF/IID providers will be grouped into two (2) functional categories: (a) ICF/IIDs larger than 15 beds. (b) ICF/IIDs (15 beds or less). (2) Within each grouping, the following methodology shall apply: cost reports, as submitted, will be desk audited for any unallowable co…

(1) The Medicaid Inflation Index will be used in lieu of budgeting to adjust certain actual allowable costs from the reporting period for the purpose of computing the prospective per diem rate payable and for such other adjustments as may be specified in this chapter. (2) The Med…

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

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

(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 resident care. Loans which result in excess funds or which are not related to resi…

(1) Allowable costs will be limited to the laundry costs which are ordinary and necessary to the operation of an ICF/IID facility and will not include costs associated with the personal laundry of residents (if the facility charges for resident personal laundry). (2) Examples of …

(1) Travel that is necessary and that is directly related to the operation of the ICF/IID facility claiming reimbursement for the expense will be an allowable cost for reimbursement purposes pursuant to the following specific provisions. (a) Automobile (This section (a) does not …

This rule does not apply to state owned and operated facilities who are paid a use allowance in lieu of depreciation, for building and improvements. The annual use allowance for buildings and improvements shall be two percent of acquisition cost. Major movable equipment for State…

(1) A provider who constructs, leases, or purchases a facility may request reimbursement based on an operating budget, subject to the ceiling established under Rules 560-X-42-.04 and 560-X-42-.05 of this Chapter. In this event, the facility will be subject to a retroactive adjust…

(1) An allowance for reasonable return on equity capital invested and used in providing patient care is allowable as an element of the reasonable cost of services rendered by a proprietary provider. (2) Equity capital is the difference between the net assets and net liabilities o…

(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) Under no circumstance…

(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 ICF/IID 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 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 are not limited to: (a) Depreciation (b) Administrative and General (c) Emp…

(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 September 30th. The complete uniform cost report must be received by Medicaid on or before November 30th. Should November 30th fall on a state holiday or weekend, the comp…