Alabama Administrative Code

(1) A citizens' advisory committee (CAC) shall advise an integrated care network (ICN) on ways it may be more efficient in providing quality care to Medicaid beneficiaries. In addition, a CAC shall carry out other functions and duties assigned to it by the ICN and approved by the…

Notes Ala. Admin. Code r. 560-X-64-.05 Adopted by Alabama Administrative Monthly Volume XXXV, Issue No. 03, December 30, 2016, eff. 1/26/2017. Repealed by Alabama Administrative Monthly Volume XXXVI, Issue No. 11, August 31, 2018, eff. 7/26/2018. Repealed by Alabama Administrativ…

(1) The Integrated Care Network (ICN) as a condition to the risk contract between the Medicaid Agency and the ICN, shall maintain minimum capital, surplus, or any combination thereof, of one million dollars ($1,000,000), unless otherwise specified by the Medicaid Agency as provid…

(1) Definitions - As referenced in this Chapter of the Alabama Medicaid Administrative Code the following terms shall be defined as follows: (a) Care Management Organization (CMO) is defined as an organization providing case management for the 1915(c) waivers enrolled in the ICN …

Notes Ala. Admin. Code r. 560-X-64-.08 Amended by Alabama Administrative Monthly Volume XXXV, Issue No. 09, June 30, 2017, eff. 7/24/2017. Repealed by Alabama Administrative Monthly Volume XXXVI, Issue No. 10, July 31, 2018, eff. 8/26/2018. Author: Stephanie Lindsay, Administrato…

(1) As used in this rule, the following terms have the meanings set forth below: (a) Enrollee means a Medicaid beneficiary enrolled as a member of an Integrated Care Network (ICN). (b) Large Print means printed in a font size no smaller than 18 point. (c) Limited English Proficie…

(1) An Integrated Care Network ("ICN") shall provide to the Medicaid Agency a periodic financial report setting forth information concerning the ICN's capital and surplus, and such other information as the Medicaid Agency may require, in such form and content and at such frequenc…

Notes Ala. Admin. Code r. 560-X-64-.11 Adopted by Alabama Administrative Monthly Volume XXXV, Issue No. 11, August 31, 2017, eff. 9/25/2017. Repealed by Alabama Administrative Monthly Volume XXXVI, Issue No. 11, August 31, 2018, eff. 7/26/2018. Repealed by Alabama Administrative …

Notes Ala. Admin. Code r. 560-X-64-.12 Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 01, October 31, 2017, eff. 11/13/2017. Repealed by Alabama Administrative Monthly Volume XXXVI, Issue No. 10, July 31, 2018, eff. 8/26/2018. Author: Stephanie Lindsay, Adminis…

(1) The Integrated Care Network (ICN) shall adopt a conflict of interest policy for directors and officers. The conflict of interest policy shall require all directors and officers to conduct their activities as directors or officers so that they do not advance or protect their o…

Notes Ala. Admin. Code r. 560-X-64-.14 Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 01, October 31, 2017, eff. 11/28/2017. Repealed by Alabama Administrative Monthly Volume XXXVI, Issue No. 10, July 31, 2018, eff. 8/26/2018. Author: Stephanie Lindsay, Adminis…

(1) An integrated care network (ICN) that has been sanctioned by the Medicaid Agency in accordance with Alabama Medicaid Administrative Code Chapter 560-X-64 may request a fair hearing. (2) An ICN's request for a fair hearing with the Medicaid Agency relating to the imposition of…

(1) The following groups of eligible Medicaid beneficiaries shall be included for coverage by an integrated care network (ICN): (a) Individuals that meet the current admission criteria for nursing facility care as described in Alabama Medicaid Administrative Code Rule 560-X-10-.1…

(1) The following services must be covered for Medicaid recipients who are enrolled in an integrated care network (ICN): (a) Direct Home and Community-Based Service Case Management for the Alabama Community Transition (ACT) Waiver in accordance with Alabama Medicaid Administrativ…

(1) Bases for Imposition of Sanctions on ICNs. The Medicaid Agency may impose sanctions on an integrated care network ("ICN") if the Medicaid Agency determines in its sole discretion that the ICN has violated any applicable federal or state law or regulation, the Alabama Medicaid…

(1) The Integrated Care Network (ICN) shall be subject to a readiness assessment period before it may begin providing services to enrollees. (2) The ICN must demonstrate readiness, to the Medicaid Agency's satisfaction, as specified in the risk contract. (3) The Medicaid Agency w…

(1) The Title XIX (Medicaid) Plan for Alabama provides for inpatient care for adults and children in accordance with 42 C.F.R. §440.10 and for preventive, diagnostic, therapeutic, rehabilitative, or palliative outpatient services in accordance with 42 C.F.R. §440.20. Inpatient ho…

(1) Eligibility. In order to participate in the Title XIX Medicaid program and to receive Medicaid payment for inpatient and outpatient hospital services, a hospital provider must meet the following requirements:(a) Be certified for participation in the Title XVIII Medicare and T…

(1) An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. A person is considered an inpatient with the expectation that he will remain at least overnight and occupy a bed (even though it later develop…

(1) Medicaid will pay for semiprivate accommodations (two, three, or fourbed accommodations). When accommodations other than semiprivate are furnished, the following rules will govern: (a) Private rooms medically necessary Payment may be made for private room or other accommodati…

Nursing and other related services, use of hospital facilities, and the medical social services ordinarily furnished by the hospital for the care and treatment of inpatients are covered. Author: Notes Ala. Admin. Code r. 560-X-7-.05 Rule effective October 1, 1982. Statutory Autho…

(1) Drugs and biologicals for use in the hospital which are ordinarily furnished by the hospital for the care and treatment of inpatients are covered. (2) Takehome drugs and medical (3) A patient may, on discharge from the hospital, take home remaining amounts of drugs which have…

(1) Supplies, appliances, and equipment furnished by the hospital solely for the care and treatment of a recipient during an inpatient stay in the hospital are covered as part of the hospital per diem payment. (2) Supplies, appliances, and equipment furnished to an inpatient for …

(1) Hemodialysis for chronic renal cases is provided under the Medicaid Program when the patient is not authorized this care under Medicare. (2) Refer to Chapter One, Rule No. 560-X-1-.27, of the Administrative Code for kidney transplant coverage. Author: Notes Ala. Admin. Code r…

Charges for whole blood or equivalent quantities of packed red cells are not allowable since Red Cross provides blood to hospitals. However, blood processing and administration is a covered service. Author: Vicki W. Huff Notes Ala. Admin. Code r. 560-X-7-.09 Rule effective Octobe…

(1) Surgical procedures for male and female recipients as method of birth control are covered services under the conditions set forth in the chapter pertaining to Family Planning. (2) Any Alabama Medicaid hospital claim that relates to any sterilization or hysterectomy must have …

Payment for abortions under the Medicaid Program is subject to the conditions in the chapter pertaining to Physicians. See the Physicians' Chapter for further details. Author: Charles A. Reasner Notes Ala. Admin. Code r. 560-X-7-.11 Rule effective October 1, 1982. Amended effecti…

(1) Physical therapy is a covered service based on medical necessity. Physical therapy services that do not require the professional skills of a qualified physical therapist to perform or supervise are not considered medically necessary. Physical therapy is covered:(a) in a hospi…

(1) This rule applies to inpatient hospital admissions beginning dates of admission on or after July 1, 2010. (2) Adverse Events are the events that must be reported to Medicaid by the hospital. To be reportable, these events must meet the following criteria: (a) The event must b…

Items and services in connection with the care, treatment, filling, removal or replacement of teeth, or structures directly Early and Periodic Screening, Diagnosis, and Treatment program. See Chapter 15, Dental Services for details. Authors: Ruth H. Chambliss, Charles A. Reasner.…

(1) Items and services for which there is no legal obligation to pay -- Free services are excluded from coverage, (e.g., chest x-rays provided without charge by health organizations). (2) Items and Services which are required as a result of war -- Those required as a result or ac…

(1) Medicaid will utilize Alabama Medicaid Adult and Pediatric Inpatient Care Criteria (SI/IS) for utilization review, billing and reimbursement purposes. (a) It is the hospital's responsibility to utilize its own physician advisor. (b) The attending physician and/or resident may…

(1) "Outpatient hospital services" means preventive, diagnostic, therapeutic, rehabilitative, or palliative services provided to an outpatient by or under the direction of a physician/dentist at a licensed hospital. (2) Medical services provided in the outpatient department must …

(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…

Author: Notes Ala. Admin. Code r. 560-X-7-.19 Rule effective October 1, 1982. Repealed: Filed August 6, 1999; effective September 10, 1999. Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.

Reference Chapter 6 Physicians and Chapter 23 Hospital Reimbursement Program for details. Authors: Ruth H. Chambliss, Charles A. Reasner Notes Ala. Admin. Code r. 560-X-7-.20 Rule effective October 1, 1982. Amended effective January 8, 1985; June 8, 1985; May 11, 1987. Statutory …

Based on PL 9735, the "Omnibus Budget Reconciliation Act of 1981," Section 2164(a) and 42 CFR Part 441.12, effective October 1, 1981, Medicaid will pay only for laboratory tests or xrays or any other type of test provided in inpatient or outpatient hospital facilities which have …

(1) For claim filing guidelines, refer to Chapter 5, (Filing Claims) of the Provider Manual or Chapter 19 (Hospital) of the Provider Manual. (2) Claims containing fragmentation of services may be recouped through post-payment review. Notes Ala. Admin. Code r. 560-X-7-.22 Rule eff…

For guidelines on submitting claims to Medicaid when a third party is involved, refer to the Hospital Billing Manual. Author: Lynn Sharp, Associate Director, Policy Development Unit Notes Ala. Admin. Code r. 560-X-7-.23 Rule effective October 1, 1982. Amended: Filed August 6, 199…

(1) Providers should not send recipients bills or statements for covered services once that recipient has been accepted as a Medicaid patient. (2) Providers may send a notice to the recipient stating their claim is still outstanding if the notice indicates in bold letters: "THIS …

(1) Out-of-State Referrals -- Prior authorization will be required for organ transplants and select surgical procedures. (Refer to Rule No. 560-X-1-.27 and Rule No. 560-X-6-.13 respectively). (2) Dental Hospitalization -- See Chapter 15, Dental Services, for details. Notes Ala. A…

(1) Inpatient Refer to Rule 560-X-1-.14 for details. (2) Outpatient Part B. Payment for outpatient crossover claims shall be based on the lesser of the coinsurance and/or deductible amount or the Medicare allowed amount times the outpatient percentage rate minus the Medicare paid…

Notes Ala. Admin. Code r. 560-X-7-.27 Rule effective October 1, 1982. Amended effective November 10, 1983. Emergency rule effective July 1, 1987. Amended effective September 9, 1987. (Ed. Note: Previously Rule No. 560-X-7-.28.) Amended: Filed March 7, 1997; effective April 11, 19…

(1) The Medicaid recipient shall pay the allowable copayment amount for each inpatient admission under the Medicaid program, except for the designated exemptions. The copayment amount does not apply to services provided for the following: (a) Recipient under 18 years of age (b) P…

(1) Payment for all outpatient hospital services will be from approved rates as established by Medicaid. (2) Publicly owned hospitals and hospitals which predominantly treat children under the age of 18 years may be paid at an enhanced payment. These payments shall not exceed com…

(1) Inpatient hospital services rendered at an inappropriate level of care (lower than acute) are considered posthospital extended care services. The patient must have received a minimum of three consecutive days of acute care services in the hospital requesting Post-Hospital Ext…

(1) Independent Rural Health Clinics must be Medicare certified and contracted with the Alabama Medicaid Program, and be in compliance with Federal, State and Local Laws. (2) Services covered under the Independent Rural Health Clinic Program are any medical service typically furn…

(1) The following services are covered as other ambulatory services furnished in an Independent Rural Health Clinic and are not billed as Rural Health Clinic services: (a) Dental Services, (b) Eyeglasses; (c) Hearing aids; (d) Prescribed devices; (e) Prosthetic devices and (f) Du…

(1) Independent Rural Health Clinics (IRHCs) will be reimbursed under a Prospective Payment System (PPS) as described in Chapter 56 of the Administrative Code. (2) Encounters are all-inclusive and all services provided for the visit are included in the reimbursement rate. The onl…

Medicaid must be notified within thirty (30) days of the date of Independent Rural Health Clinic 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 po…