Alabama Administrative Code

Notes Ala. Admin. Code r. 560-X-58-.08 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 Repealed: Filed April 5, 1999; effective May 10, 1999.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…

Notes Ala. Admin. Code r. 560-X-58-.09 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 Repealed: Filed April 5, 1999; effective May 10, 1999.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. Repealed by Alabama Administrative Month…

Notes Ala. Admin. Code r. 560-X-58-.10 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 Repealed: Filed April 5, 1999; effective May 10, 1999.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-.11 Emergency rule effective July 20, 1992. Permanent rule effective October 15, 1992. Repealed: Filed April 5, 1999; effective May 10, 1999. New Rule: Filed June 20, 2003; effective September 15, 2003. Amended: Filed June 12, 2012; effective Ju…

Notes Ala. Admin. Code r. 560-X-58-.12 New Rule: Filed August 11, 2003; effective September 15, 2003. Repealed by Alabama Administrative Monthly Volume XXXVI, Issue No. 10, July 31, 2018, eff. 8/26/2018. Author: Felecia Barrow, Associate Director, LTC Project Development Unit. St…

(1) A Provider-Based Rural Health Clinic (PBRHC) is a rural health clinic that is an integral and subordinate part of a hospital, skilled nursing facility, or a home health agency participating in Medicare and is operated with other departments of the provider under common licens…

(1) In order to participate in the Title XIX (Medicaid) Program, and to receive Medicaid payment, a Provider-Based Rural Health Clinic, including satellite clinics must: (a) request an enrollment packet from our Fiscal Agent Provider Enrollment Unit; (b) be certified for particip…

(1) Services covered in the Provider-Based Rural Health Clinic are: (a) Medically necessary diagnostic and therapeutic services and supplies that are an incident to such services or as an incident to a physician's service and that are commonly furnished in a physician's office or…

(1) The following services are covered as other ambulatory services furnished in a Provider-Based Rural Health Clinic and are considered rural health clinic services: (a) Dental services; (b) Eyeglasses; (c) Hearing Aids; (d) Prescribed devices; (e) Prosthetic devices; (f) Durabl…

(1) Provider-Based Rural Health Clinics will be reimbursed under a prospective payment system as described in Section 1902(aa) of the Social Security Act. Refer to Alabama Administrative Code Chapter 60. (2) Inpatient and outpatient surgery is reimbursed as fee for service and is…

For Provider-Based Rural Health Clinic services, Medicare deductible and/or coinsurance will be reimbursed up to the full amount of the Medicaid encounter rate. Author: Carol Akin, Associate Director, Clinic/Ancillary Services Notes Ala. Admin. Code r. 560-X-59-.06 Emergency rule…

The provider must notify Medicaid within thirty (30) days of the date of ownership change of a Provider-Based Rural Health Clinic. The existing contract will be automatically assigned to the new owner. The new owner shall then be required to execute a new contract with Medicaid a…

(1) Medicaid and Medicare/Medicaid related recipients are required to pay and Provider-Based Rural Health Clinics are required to collect the established copayment amount for each clinic visit. (2) The cost-sharing requirement does not apply to services provided for the following…

(1) A provider agrees to accept as payment in full the amount paid by the State, 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) A provider may bil…

(1) The term "physician" shall mean(a) a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the state in which the doctor performs such functions; (b) a doctor of dentistry or of dental or oral surgery who is licensed to practice in the state …

(1) Effective March 1, 2010, all claims that do not require attachments (TPL denial), manual review (unclassified J codes), and an Administrative Review override by Medicaid or additional information to be printed on the claim (Work Incentive Program) must be submitted electronic…

Hospital-based physicians will be reimbursed under the same general system as is used in Medicare. Bills for services rendered will be submitted as follows: (1) All hospital-based physicians, including emergency room physicians, radiologists, and pathologists, shall bill the Medi…

(1) MEDICAID ELIGIBLES. (a) Claims should be submitted to the fiscal agent in accordance with instructions for these patients who are enrolled for MEDICAID ONLY. (b) Reimbursement for physicians' services will NOT be made to the patient, sponsor, or nursing facility. The Medicaid…

Out of State Claims DO NOT Need Prior Approval. Except for those services which require prior approval as stated in Chapters 1 and 6 of this Administrative Code (i.e. transplants and select surgeries), medical care outside the State of Alabama does not require prior authorization…

Payment from Medicaid funds can be made to the actual provider of service only. The only exceptions to this rule are payments made within the same group, or for substitute physicians. Authors: Janet B. Young; Debra Moore Notes Ala. Admin. Code r. 560-X-6-.06 Rule effective Octobe…

(1) An outofstate physician who wishes to participate in the Alabama Medicaid Program must enroll with the Alabama Medicaid Program and be assigned a provider identification number. To do so, the physician should send a written request to Medicaid's fiscal agent, Provider Enrollm…

Refer to the rules regarding consent and authorization contained in paragraphs within this chapter regarding sterilization, and abortions, Chapter 14 of this Code, and to Title 22, Chapter 8, Code of Ala. 1975. Note: Nontherapeutic sterilization performed for the sole purpose of …

(1) Abortions: A claim seeking payment for an abortion must be accompanied by one or more (depending on the circumstance) of the forms required by federal law and a copy of the medical records. Payment is available for abortions as provided under federal law. (a) In the event the…

(1) For information about hospital certification and recertification see Rule 560-X-7-.16. (2) In a skilled or intermediate nursing care facility, in the hospital and for the Home Health Care Program, Medicaid patients must be recertified by a physician at least every sixty (60) …

With the exception of Medicaid recipients eligible for treatment under the EPSDT (MediKids) program, additional hospital days are not covered. Refer to Chapter 7, Hospital Program and Chapter 11, EPSDT, for specifics. Author: Notes Ala. Admin. Code r. 560-X-6-.11 Rule effective O…

(1) In general, physician services are covered by Medicaid if the services are: (a) Considered medically necessary by the attending physician. However, when the persons designated responsible for utilization review have issued a denial for inpatient days, no ancillary charge or p…

(1) Acupuncture: Not covered. (2) Administration of anesthesia is a covered service when administered by or directed by a duly licensed physician for a medical procedure which is a covered service under the Alabama Medicaid Program. Medical direction by an anesthesiologist of mor…

(1) Within each calendar year each recipient is limited to no more than a total of 14 physician office visits in offices, hospital outpatient settings, nursing homes, or Federally Qualified Health Centers. Visits counted under this quota will include, but not be limited to, visit…

Notes Ala. Admin. Code r. 560-X-6-.15 Rule entitled "Services to Hospital Patients Whose Benefit Days Have Expired" effective October 1, 1982. Amended effective July 8, 1983; July 9, 1984; March 12, 1987. Repealed effective July 10, 1987.

A provider 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 balance of…

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

(1) When caring for a critically ill patient in which the constant attention of the physician is required, the appropriate critical care procedure code must be billed. Refer to the CPT and the Alabama Medicaid Provider Manual for additional guidance and clarification. (2) The act…

(1) All physician services rendered to each outpatient maintenance dialysis patient provided during a full month on an ongoing basis without interruption of the treatment regime (uninterruptedly) shall be billed on a monthly capitation basis. The monthly capitation payment is lim…

This Chapter states the Medicaid policy regarding Provider Based Rural Health Clinics (hereinafter referred to as PBRHCs) reimbursement and establishes the accepted procedures whereby reimbursement is made to PBRHC providers. Because of the length and complexity of this Chapter, …

(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 PBRHCs and to help ensure that the reasonable cost regulations are uniformly applied state wide w…

(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 Provider Based Rural Health Clinics (PBRHCs) 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 Secu…

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

(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 clinic 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…

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 operat…

(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 - Cost report filing, using Medicaid prescribed cost report forms, is mandatory for new PBRHCs when (1) submitting an operating budget to establish a budget rate and (2) submitting actual cost to settle the budgeted period. Each new PBRHC will have its own National Pr…

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

(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 the Provider Audit Section at Medicaid withi…

(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…