22-6-224
Section 22-6-224 Medicaid Agency to contract for medical care; enrollment; delivery of services; reimbursement. (a) Subject to approval of the federal Centers for Medicare and Medicaid Services, the Medicaid Agency shall enter into contracts with one or more integrated care networks to provide, pursuant to a risk contract under which the Medicaid Agency makes a capitated payment, medical care to Medicaid beneficiaries assigned to the integrated care network. The Medicaid Agency may enter into a contract pursuant to this section only if, in the judgment of the Medicaid Agency, care of Medicaid beneficiaries would be better, more efficient, and less costly than under the then existing care delivery system. Pursuant to the contract, the Medicaid Agency shall set capitation payments for the integrated care network. (b) The Medicaid Agency shall enroll beneficiaries it designates into an integrated care network consistent with guidance from the Center for Medicare and Medicaid Services. (c)...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/22-6-224.htm - 1K - Match Info - Similar pages
22-6-153
Section 22-6-153 Contract to provide medical care to Medicaid beneficiaries; enrollment; grievance procedures; duties of Medicaid Agency. (a) Subject to approval of the federal Centers for Medicare and Medicaid Services, the Medicaid Agency shall enter into a contract in each Medicaid region for at least one fully certified regional care organization to provide, pursuant to a risk contract under which the Medicaid Agency makes a capitated payment, medical care to Medicaid beneficiaries. However, the Medicaid Agency may enter into a contract pursuant to this section only if, in the judgment of the Medicaid Agency, care of Medicaid beneficiaries would be better, more efficient, and less costly than under the then existing care delivery system. The Medicaid Agency may contract with more than one regional care organization in a Medicaid region. Pursuant to the contract, the Medicaid Agency shall set capitation payments for the regional care organization. (b) The Medicaid Agency shall...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/22-6-153.htm - 10K - Match Info - Similar pages
22-6-226
Section 22-6-226 Review and approval of contracts; rules governing operation of integrated care networks. (a) All provider contracts of an organization granted final certification as an integrated care network shall be subject to review and approval of the Medicaid Agency. (b)(1) If a provider is dissatisfied with any term or provision of the agreement or contract offered by an integrated care network, the provider shall: a. Seek redress with the integrated care network. In providing redress, an integrated care network shall afford the provider a review by a panel composed of a representative of an integrated care network, the same type of provider, and a representative of the citizens' advisory board appointed by the chair of the advisory board. b. After seeking redress with an integrated care network, a provider or an integrated care network who remains dissatisfied may request a review of such disputed term or provision by the Medicaid Agency. The Medicaid Agency shall have 10 days...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/22-6-226.htm - 3K - Match Info - Similar pages
22-6-233
Section 22-6-233 Legislative findings; certification of collaborators; powers of Medicaid Agency; state action immunity. (a) The Legislature declares that collaboration among public payers, private health carriers, third party purchasers, and providers to identify appropriate service delivery systems and reimbursement methods in order to align incentives in support of integrated and coordinated health care delivery is in the best interest of the public. Collaboration pursuant to this article is to provide quality health care at the lowest possible cost to Alabama citizens who are Medicaid eligible. The Legislature, therefore, declares that this health care delivery system affirmatively contemplates the foreseeable displacement of competition, such that any anti-competitive effect may be attributed to the state's policy to displace competition in the delivery of a coordinated system of health care for the public benefit. In furtherance of this goal, the Legislature declares its intent...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/22-6-233.htm - 6K - Match Info - Similar pages
22-6-220
Section 22-6-220 Definitions. For the purposes of this article, the following words shall have the following meanings: (1) CAPITATION PAYMENT. A payment the state Medicaid Agency makes periodically to the integrated care network on behalf of each recipient enrolled under a contract for the provision of medical services pursuant to this article. (2) COLLABORATOR. A private health carrier, third party purchaser, provider, health care center, health care facility, state and local governmental entity, or other public payers, corporations, individuals, and consumers who are expecting to collectively cooperate, negotiate, or contract with another collaborator, or integrated care network in the health care system. (3) INTEGRATED CARE NETWORK. One or more statewide organizations of health care providers, with offices in each regional care organization region, that contracts with the Medicaid Agency to provide Medicaid benefits to certain Medicaid beneficiaries as defined in subdivision (4) and...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/22-6-220.htm - 3K - Match Info - Similar pages
22-6-221
Section 22-6-221 Service by integrated care network; board of directors. (a) An integrated care network shall serve only Medicaid beneficiaries in providing medical care and services. For the purposes of this article, a beneficiary cannot be a member of both an integrated care network and a regional care organization. (b) An integrated care network shall provide required medical care and services to Medicaid beneficiaries and may coordinate care provided by or through an affiliation of other health care providers or other programs as the Medicaid Agency shall determine. (c) Notwithstanding any other provision of law, the integrated care network shall not be deemed an insurance company under state law. (d)(1) An integrated care network shall have a governing board of directors composed of the following members: a. Twelve members shall be persons representing risk bearing participants. A participant bears risk by contributing cash, capital, or other assets to the integrated care network....
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22-6-230
Section 22-6-230 Rates for contracting services; provider requirements. An integrated care network shall contract with any willing nursing home, doctor, home and community waiver program, or other provider to provide services through an integrated care network if the provider is willing to accept the payments and terms offered comparable providers, where applicable, but in no event less than amounts historically paid by the Medicaid Agency to comparable providers. To the extent that the Medicaid Agency currently calculates and establishes provider-specific rates for any provider category on an annualized basis, it shall continue to calculate and establish such rates and the integrated care network shall be required to offer providers from that category not less than their established rates. Any provider shall meet licensing requirements set by law, shall have a Medicaid provider number, and shall not otherwise be disqualified from participating in Medicare or Medicaid. (Act 2015-322,...
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40-26B-70
Section 40-26B-70 Definitions. For purposes of this article, the following terms shall have the following meanings: (1) ACCESS PAYMENT. A payment by the Medicaid program to an eligible hospital for inpatient or outpatient hospital care, or both, provided to a Medicaid recipient. (2) ALL PATIENT REFINED DIAGNOSIS-RELATED GROUP (APR-DRG). A statistical system of classifying any non-Medicare inpatient stay into groups for the purposes of payment. (3) ALTERNATE CARE PROVIDER. A contractor, other than a regional care organization, that agrees to provide a comprehensive package of Medicaid benefits to Medicaid beneficiaries in a defined region of the state pursuant to a risk contract. (4) CERTIFIED PUBLIC EXPENDITURE (CPE). A certification in writing of the cost of providing medical care to Medicaid beneficiaries by publicly owned hospitals and hospitals owned by a state agency or a state university plus the amount of uncompensated care provided by publicly owned hospitals and hospitals...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/40-26B-70.htm - 5K - Match Info - Similar pages
22-6-163
Section 22-6-163 Legislative findings; rules; collaboration; approval of agreements and contracts; state action immunity; confidentiality of records; additional duties. (a) The Legislature declares that collaboration among public payers, private health carriers, third party purchasers, and providers to identify appropriate service delivery systems and reimbursement methods in order to align incentives in support of integrated and coordinated health care delivery is in the best interest of the public. Collaboration pursuant to this article is to provide quality health care at the lowest possible cost to Alabama citizens who are Medicaid eligible. The Legislature, therefore, declares that this health care delivery system affirmatively contemplates the foreseeable displacement of competition, such that any anti-competitive effect may be attributed to the state's policy to displace competition in the delivery of a coordinated system of health care for the public benefit. In furtherance of...
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27-1-17
Section 27-1-17 Limitation periods for payment of claims; overdue claims; retroactive denials, adjustments, etc.; penalties. (a) Each insurer, health service corporation, and health benefit plan that issues or renews any policy of accident or health insurance providing benefits for medical or hospital expenses for its insured persons shall pay for services rendered by Alabama health care providers within 45 calendar days upon receipt of a clean written claim or 30 calendar days upon receipt of a clean electronic claim. If the insurer, health service corporation, or health benefit plan is denying or pending the claim, the insurer, health service corporation, or health benefit plan shall, within 45 calendar days for a written claim and 30 calendar days for an electronic claim, notify the health care provider or certificate holder of the reason for denying or pending the claim and what, if any, additional information is required to process the claim. Any undisputed portion of the claim...
alisondb.legislature.state.al.us/alison/CodeOfAlabama/1975/27-1-17.htm - 17K - Match Info - Similar pages
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