Alabama Administrative Code

Notes Ala. Admin. Code r. 560-X-46-.09 Emergency rule effective March 30, 1989. Permanent rule effective July 13, 1989. Repealed: Filed November 12, 2013; effective December 17, 2013. Author: Vicki Huff Statutory Authority: Title XIX, Social Security Act; State Plan, Attachment 4…

Providers of swing bed care must execute a Nursing Facility/Patient Agreement for each Medicaid patient on admission and when any financial terms change. This agreement is executed for patients already eligible for Medicaid and patients who are applying for Medicaid eligibility. …

(1) Rehabilitative services are specialized services of a medical or remedial nature delivered by uniquely qualified practitioners designed to treat or rehabilitate persons with mental illness or substance abuse diagnoses. These services will be provided to recipients on the basi…

(1) Financial eligibility is limited to individuals eligible for Medicaid under the Alabama State Plan. (2) Treatment eligibility is limited to individuals with a diagnosis, assigned by a licensed physician, a licensed psychologist, a licensed physician's assistant, a certified r…

To participate in the Alabama Medicaid Program, rehabilitative services providers must meet the following requirements. Service providers must demonstrate that they meet the criteria in either (1), (2), or (3), and both (4) AND (5) below. (1) A provider must be certified as a 310…

(1) Mental Health MI Professional Staff qualifications are delineated within the specifications for each covered mental health rehabilitation service as described in the applicable Alabama Medicaid Agency Provider Manual, MI/SA Rehabilitative Services, Chapter 105. (2) Substance …

(1) Requirements for intake, treatment planning, and service documentation are detailed in the Medicaid Provider Manual, Rehabilitative Services, Chapter 105, Section 105.2.3. Manuals may be downloaded from the Medicaid website at www.medicaid.alabama.gov. (2) Documentation in th…

(1) Only the rehabilitative services delineated in the applicable Alabama Medicaid Agency Provider Manual, Rehabilitation Services, Chapter 105 shall qualify for reimbursement under this program. (2) A complete description of each covered service along with benefit limitations is…

(1) A statewide maximum payment will be calculated for each service designated by a procedure code recognized by the Alabama Medicaid Agency as a covered service. (2) The Medicaid reimbursement for each service provided by a rehabilitative services provider shall be based on the …

(1) The rehabilitative services provider shall make all reasonable efforts to determine if there is a liable third party source, including Medicare, and in the case of liable third party source, utilize that source for payments and benefits prior to applying for Medicaid payments…

(1) Payment made by Medicaid to a rehabilitative services provider shall be considered to be payment in full for covered services rendered. (2) No Medicaid recipient shall be billed for covered Medicaid services in part or in full for those services rendered, billed, and paid to …

A rehabilitative services provider shall not use or disclose, except to duly authorized representatives of federal or state agencies, any information concerning a recipient, except upon the written consent of the recipient, his attorney, his guardian, or upon subpoena from a cour…

(1) The rehabilitative services provider 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 …

(1) Federally Qualified Health Centers (FQHCS) are defined as health care centers which meet one of the following requirements: (a) receives a grant under Section 329, 330, 340, or 340A of the Public Health Services Act; (b) meets the requirements for receiving such a grant as de…

(1) In order to participate in the Title XIX Medicaid Program and to receive Medicaid payments, a FQHC must: (a) Submit a complete enrollment packet to the Fiscal Agent, including a list of all satellite centers and addresses. (b) Submit appropriate documentation from the Departm…

(1) Federally Qualified Health Centers (FQHCs) will be reimbursed under a prospective payment system as described in Chapter 56 of the Administrative Code. (2) Inpatient and outpatient surgery is reimbursed as fee for service and is subject to the routine benefit limitations and …

(1) Medicaid must be notified within thirty (30) days of the date of a FQHC ownership change. The existing contract will be automatically assigned to the new owner, and the new owner shall then be required to execute a new contract with Medicaid as soon as possible after the chan…

(1) Coinsurance will be paid up to the established Medicaid reimbursement rate for each FQHC. Author: Vicki Huff Notes Ala. Admin. Code r. 560-X-48-.05 Emergency rule effective October 1, 1990. Permanent rule effective January 15, 1991. Amended: April 15, 1993. Amended: Filed Nov…

(1) Medicaid and Medicare/Medicaid related recipients are required to pay and the FQHCs are required to collect the established copayment amount for each medical encounter. (2) The cost-sharing amount does not apply to services provided for the following: (a) Recipients under 18 …

(1) A provider agrees to accept as payment in full the amount paid by Medicaid, plus any copayment amount required to be paid by the recipient for covered items, and further agrees to make no additional charge or charges for covered items to the recipient. (2) Billing recipients …

(1) While a recipient signature is not required on individual claim forms, all providers must obtain a signature to be kept on file, e.g., release forms or sign-in-sheets, as verification that the recipient was present on the date of service for which the provider seeks payment. …

(1) Nurse practitioners who are certified by the appropriate national organization as a family nurse practitioner, pediatric nurse practitioner, women's health care practitioner, or neonatal nurse practitioner are eligible to participate in the Alabama Medicaid Program. (2) A nur…

(1) In order to participate in the Alabama Medicaid Program, a nurse practitioner must complete an enrollment application which is obtained from the Agency's Fiscal Agent. (2) The completed application must be returned to the Fiscal Agent for processing along with the following i…

(1) Nurse practitioners may only bill and be directly reimbursed for those services that are listed in the provider billing manual. (2) In order for services to be covered, nurse practitioners must be under the supervision of a licensed physician. Author: Debra Moore Notes Ala. A…

Limitations on services provided by nurse practitioners are the same as those for a physician and will be counted in the physician visit quota. See Rule 560-X-6-.14. Author: Debra Moore Notes Ala. Admin. Code r. 560-X-49-.04 Emergency rule effective May 22, 1991. Permanent rule e…

A nurse practitioner may bill Medicaid recipients for the copay amount, for Medicaid noncovered services and for services provided to a recipient who has exhausted his/her yearly limitations. Conditional collections to be refunded post payment by Medicaid and partial charges for …

Nurse practitioners 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 Administrative Code. Author: Debra Moore Notes Ala. Admin. Code r. 560-X-49-.06 Emergency rule…

(1) Medicaid recipients are required to pay, and nurse practitioners are required to collect, the designated copayment amount on each visit. The copayment amount does not apply to services provided for the following: (a) Pregnancy (b) Nursing home residents (c) Inpatient hospital…

(1) Inpatient psychiatric services for recipients age 65 or over, are covered services when provided: (a) In a free-standing psychiatric hospital exclusively for the treatment of persons age 65 or over with serious mental illness (as defined in the Diagnostic and Statistical Manu…

(1) In order to participate in the Title XIX Medicaid program and to receive Medicaid payment for inpatient services for individuals 65 and older, a provider must meet the following requirements:(a) Be certified for participation in the Medicare/Medicaid program; (b) Be licensed …

(1) For purposes of this chapter, an inpatient is a person, age 65 or over, who has been admitted to a freestanding psychiatric facility specializing in the diagnosis, treatment and care of geriatric patients occupying beds, for the purpose of maintaining or restoring to the grea…

(1) Certification of need for services is a determination which is made by a physician regarding the Medicaid recipient's treatment needs for admission to the facility. (2) The physician must certify for each applicant or recipient that inpatient services in a mental hospital are…

(1) Before admission to a psychiatric facility or before authorization for payment, the attending physician, psychiatrist, or staff physician must make a medical evaluation of each individual's need for care in the facility. Appropriate professional personnel must make a psychiat…

(1) The attending physician or staff physician must establish a written plan of care for each individual before admission to a mental hospital and before authorization of payment. (2) The plan of care must include: (a) Diagnosis, symptoms or complaints indicating a need for admis…

As a condition of participation in the Title XIX Medicaid program, each psychiatric facility shall: (1) 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 facilities for individuals age 65 and older shall be the per diem rate established by Medicaid for the hospital, which is based on the Medicaid cost report and all the requirements expressed in Chapter 23 of the Alabama M…

(1) The Medicaid Quality Assurance Program will periodically perform an inspection of care and services provided to recipients in accordance with 42 C.F.R. Part 456, Subpart I. The review team must consist of psychiatrist or physician with knowledge and experience in the provisio…

(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. (3) For an individual who appli…

(1) The hospital's utilization review personnel will be responsible for performing continued stay reviews on recipients who require continued inpatient hospitalization. (2) The initial continued stay review should be performed on the date assigned by Medicaid. Subsequent reviews …

(1) Preventive Health Education Services are services provided by a physician or other licensed practitioner of the healing arts (within the scope of practice), or by other qualified providers, which are designed to prevent disease, disability, or other health conditions or their…

(1) Eligible persons may receive preventive health education services through providers who are under contractual agreement with Medicaid to provide these services. (2) Providers include clinics or other organizations which utilize licensed practitioners of the healing arts withi…

(1) Eligibility of recipients for preventive health education services varies according to the type of service being provided. (a) Prenatal Education services are limited to those Medicaid eligible females who are pregnant (as evidenced by physical examination or a positive pregn…

(1) Preventive Health Education Services do not include services for which payment shall be made under other provisions. (2) Preventive Health Education Services are covered when provided by a Medicaid enrolled preventive health education service provider. (a) Prenatal Education …

Medicaid recipients shall not be required to pay and providers may not collect a copayment for any of these services. Refer to Rule 560-X-1-.25 for copay information. Author: Dee Lockridge Notes Ala. Admin. Code r. 560-X-50-.05 Emergency rule effective December 11, 1991. Permanen…

(1) The provider shall not charge Medicaid for services rendered on a no-cost basis to the general public except where such services are provided pursuant to Section 1903(c) of the Social Security Act or such services are provided by Title V Grantee pursuant to Section 1902(a)(11…

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

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

(1) Hospice care services are available if medically necessary for full Medicaid eligible recipients certified as being terminally ill. Medical certification is required by the individual's attending physician; however, if the recipient does not have a primary attending physician…

(1) Hospice means a public agency or private organization or a subdivision of either that is primarily engaged in providing care to terminally ill individuals, meets the Medicare conditions of participation for hospices and has a valid Medicaid provider agreement. (2) Attending p…

(1) A provider of hospice services shall meet the definition of hospice in Rule No. 560-X-51-.02(1). (2) The provider shall participate in Title XVIII (Medicare) and shall be certified under Medicare standards. (3) Within two days after hospice care is initiated, the provider sha…