Alabama Administrative Code

(1) The targeted case manager will receive referrals from hospitals, nursing homes, physicians, the community and others for persons who may be eligible for home and community-based services. (2) An assessment document will be completed by the targeted case manager in conjunction…

(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-54-.02 may request an appeal in accordance with 42 CFR Section 431, Subpart E and Chapter 3 of the Alabama Medic…

(1) Payments made by Medicaid to providers will be on a fee-for-service basis. Each covered service is identified on a claim by a procedure code. (2) Payment will be based on the number of units of service reported on the claim for each procedure code. (3) Accounting for actual c…

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 Alabama Medicaid Agency shall maintain all information regarding claims submitted and paid for services provided eligible recipients. Said records shall be retained for the period of time required by state and federal laws. (2) A sign-in log, service receipt, or some othe…

(1) Medicaid's fiscal agent enrolls providers of waiver services and issues provider contracts to applicants who meet the licensure and/or certification requirements of the State of Alabama, the Code of Federal Regulations and the Alabama Medicaid Provider Manual. (2) General enr…

(1) The Alabama Medicaid Agency will be responsible for ensuring 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) Perinatal Regional Directors serve as a liaison between the provider community, Medicaid eligible pregnant women and infants, the Department of Public Health and the Alabama Medicaid Agency. (2) The purpose of providing these services is to ensure availability of and access t…

(1) A Perinatal Regional Director must meet the requirements of a registered nurse as defined by the State Personnel Department and will be governed by such rules and regulations. (2) Hiring practices will be accomplished by the Department of Public Health. Required performance r…

(1) Perinatal Regional Directors are required to spend their billable time working on the goal of reducing infant's deaths and illness among Medicaid insured infants. Services included, but are not limited to, the following types of service: (a) Fetal and infant mortality review …

An annual report is produced by the Alabama Department of Public Health outlining the findings of the Infant Mortality and Morbidity initiative. The Medicaid Agency may perform audits of Regional Director activities. Notes Ala. Admin. Code r. 560-X-55-.04 Rule effective January 1…

The Department of Public Health will be reimbursed for providing these services as specified in the Memorandum of Understanding with the Medicaid Agency. Notes Ala. Admin. Code r. 560-X-55-.05 Rule effective January 14, 1992. Amended: Filed April 11, 2014; effective May 16, 2014.…

This Chapter states the Medicaid policy regarding Federally Qualified Health Centers, hereinafter referred to as FQHCs, reimbursement and establishes the accepted procedures whereby reimbursement is made to FQHC providers. Because of the length and complexity of this Chapter, it …

(1) This Chapter of the Alabama Medicaid Administrative Code has been published by the Alabama Medicaid Agency (Medicaid) to accommodate program needs and the administrative needs of FQHCs and to help ensure that the reasonable cost regulations are uniformly applied state wide wi…

(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) Chapter - This Chapter (C…

(1) A Medicaid prospective payment system (PPS) for Federally Qualified Health Centers (FQHCs) was enacted into law under section 702 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000. As described in section 1902(aa) of the Social Securi…

Notes Ala. Admin. Code r. 560-X-56-.05 Rule effective April 15, 1993. Repealed: Filed November 12, 2008; effective December 17, 2008. Author: Statutory Authority: State Plan; Title XIX, Social Security Act, 42 C.F.R., § 405.2401 - .2429.

(1) Encounters are face-to-face contacts between a patient and a health professional for the provision of medically necessary services. Contacts with more than one health professional and multiple contacts with the same health professional, that take place on the same day and at …

(1) Overhead costs are those costs not directly related to patient care. Overhead costs are those costs related to the FQHC's facility and administration and management of the FQHC. (2) Examples of Overhead Costs include, but are not limited to: (a) Salaries and benefit costs of …

(1) Orientation and On-The-Job Training. The costs of orientation and on-the-job training are recognized as normal operating costs and are allowable. Ordinarily, such training would be imparted within the center setting. If, however, the training requires outside instructions, co…

(1) Travel expense incurred by a facility to send employees (except physicians, which is covered below) to attend a required educational workshop within the state which increases the quality of medical care and/or the operating efficiency of the facility is an allowable cost. Wor…

(1) General Principles Relating to Property Costs. Property Costs include, but are not limited to, depreciation, interest, lease and rental payments, insurance on buildings and contents, and property taxes. In addition to the limitations contained in this rule, all property costs…

(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) A chain organization consists of a group of two or more health care facilities which are owned, leased, or through any other device, controlled by one organization. Chain organizations include, but are not limited to, chains operated by proprietary organizations and chains op…

(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 qual…

(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) General - New FQHCs must file a cost report, using Medicaid's prescribed cost report forms, when (1) submitting an operating budget to establish a budget rate and (2) submitting actual cost to settle the budget period. The due date to submit the cost report to settle the budg…

(1) Audit adjustments will be paid or collected by a combination of (1) changing the encounter 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 encounter rate change. (2) Under/Overpayment situatio…

(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 negligent 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…

(1) Home and community-based services for the SAIL Waiver are provided by the Alabama Medicaid Agency to disabled individuals who would otherwise require institutionalization in a nursing facility. These services are provided through a Medicaid waiver under the provisions of Sect…

(1) Financial eligibility is limited to those individuals receiving SSI, individuals receiving State Supplementation, SSI related protected groups deemed to be eligible for SSI/Medicaid, and Special Home and Community-Based waiver disabled individuals whose income is not greater …

The Home and Community-Based SAIL Waiver is a cooperative effort between the Alabama Medicaid Agency and the Alabama Department of Rehabilitation Services. Author: Patricia A. Harris, Administrator, LTC Program Management Unit Notes Ala. Admin. Code r. 560-X-57-.03 Emergency rule…

(1) Case Management Services. (a) Case management is a system of providing services which will assist waiver recipients in gaining needed waiver and other state plan services, as well as needed medical, social, educational, and other appropriate services, regardless of the fundin…

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 available…

(1) The case manager will receive referrals from hospitals, 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 the operating agency for funds expended on Home and Community-Based services must be maintained and provide a clearly defined audit trail. The operating agency as described in the waiver document must retain records that fully disclose the exte…

(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-57-.02, may request an appeal in accordance with 42 CFR Section 431, Subpart E and Chapter 3 of the Alabama Medi…

(1) Fiscal audits of the SAIL 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 the opportunity to…

(1) Payments made by Medicaid to providers will be on a fee-for-service basis. Each covered service is identified on a claim by a procedure code. (2) The rate will be based on audited past performance with consideration being given to the medical care portion of the consumer pric…

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

Providers shall not use or 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 or her attorney, and/or guardian, or upon subpoena from a court of appro…

Notes Ala. Admin. Code r. 560-X-58-.01 Emergency Rule effective July 20, 1992. Permanent Rule effective October 15, 1992. Repealed: Filed April 5, 1999; effective May 10, 1999. New Rule: Filed August 11, 2003; effective September 15, 2003. Amended: Filed March 14, 2007; effective…

Notes Ala. Admin. Code r. 560-X-58-.02 Emergency Rule effective July 20, 1992. Permanent rule effective October 15, 1992. Repealed: Filed April 5, 1999; effective May 10, 1999. New Rule: Filed August 11, 2003; effective September 15, 2003. Amended: Filed March 14, 2007; effective…

Notes Ala. Admin. Code r. 560-X-58-.03 Emergency Rule effective July 20, 1992. Permanent rule effective October 15, 1992. Repealed: Filed April 5, 1999; effective May 10, 1999. New Rule: Filed August 11, 2003; effective September 15, 2003. Amended: Filed March 14, 2007; effective…

Notes Ala. Admin. Code r. 560-X-58-.04 Emergency rule effective July 20, 1992. Permanent rule effective October 15, 1992. Amended: Filed January 5, 1994; effective February 10, 1994. Repealed: Filed April 5, 1999; effective May 10, 1999. New Rule: Filed August 11, 2003; effective…

Notes Ala. Admin. Code r. 560-X-58-.05 Emergency rule effective July 20, 1992. Permanent rule effective October 15, 1992. Repealed: Filed April 5, 1999; effective May 10, 1999. New Rule: Filed August 11, 2003; effective September 15, 2003. Amended: Filed March 14, 2007; effective…

Notes Ala. Admin. Code r. 560-X-58-.06 Emergency rule effective July 20, 1992. Permanent rule effective October 15, 1992. Repealed: Filed April 5, 1999; effective May 10, 1999. New Rule: Filed August 11, 2003; effective September 15, 2003. Amended: Filed March 14, 2007; effective…

Notes Ala. Admin. Code r. 560-X-58-.07 Emergency rule effective July 20, 1992. Permanent rule effective October 15, 1992. Repealed: Filed April 5, 1999; effective May 10, 1999. New Rule: Filed August 11, 2003; effective September 15, 2003. Amended: Filed August 11, 2008; effectiv…