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22-6-222
Section 22-6-222 Citizens' advisory committee. There shall be a citizens' advisory committee
constituted to advise the integrated care network on ways the integrated care network may
be more efficient in providing quality care to Medicaid beneficiaries. In addition, the advisory
committee shall carry out other functions and duties assigned to it by the integrated care
network and approved by the Medicaid Agency. The committee shall meet all of the following
criteria: (1) Be selected in a method established by the organization seeking to become an
integrated care network, or established by an integrated care network, and approved by the
Medicaid Agency. (2) At least 20 percent of its members shall be Medicaid beneficiaries or
sponsors of Medicaid beneficiaries or, if the organization has been certified as an integrated
care network, at least 20 percent of its members shall be Medicaid beneficiaries enrolled
in the integrated care network, or their sponsor. (3) Include members who are...
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22-6-122
Section 22-6-122 Medicaid Pharmacy and Therapeutics Committee - Classification and recommendation
of drugs; assurance of quality patient care; review of pharmaceutical products. (a) The Medicaid
Pharmacy and Therapeutics Committee shall review and recommend classes of drugs to the Medicaid
Commissioner for inclusion in the Medicaid Preferred Drug Plan. Class means a therapeutic
group of pharmaceutical agents approved by the FDA as defined by the American Hospital Formulary
Service. The classes of anti-retroviral and anti-psychotic drugs shall not be included in
the Medicaid Preferred Drug Plan. (b) The Medicaid Pharmacy and Therapeutics Committee shall
develop its preferred drug list recommendations by considering the clinical efficacy, safety,
and cost effectiveness of a product. Within each covered class, the committee shall review
and recommend drugs to the Medicaid Commissioner for inclusion on a preferred drug list. Generics
and over the counter drugs covered by Medicaid may be...
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22-6-154
Section 22-6-154 Quality assurance committee; collection and publication of information.
(a) The Medicaid Agency shall create a quality assurance committee appointed by the Medicaid
Commissioner. The members of the committee shall serve two-year terms. At least 60 percent
of the members shall be physicians who provide care to Medicaid beneficiaries served by a
regional care organization. In making appointments to the committee, the Medicaid Commissioner
shall seek input from the appropriate professional associations. (b) The committee shall identify
objective outcome and quality measures, including measures of outcome and quality for ambulatory
care, inpatient care, chemical dependency and mental health treatment, oral health care, and
all other health services provided by coordinated care organizations. Quality measures adopted
by the committee shall be consistent with existing state and national quality measures. The
Medicaid Commissioner shall incorporate these measures into...
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40-26B-82
Section 40-26B-82 Effectiveness and cessation. (a) The assessment imposed under this
article shall not take effect or shall cease to be imposed and any moneys remaining in the
Hospital Assessment Account in the Alabama Medicaid Program Trust Fund shall be refunded to
hospitals in proportion to the amounts paid by them if any of the following occur: (1) Expenditures
for hospital inpatient and outpatient services paid for by the Alabama Medicaid Program for
fiscal years 2020, 2021, and 2022, are less than the amount paid during fiscal year 2017.
Reimbursement rates under this article for fiscal years 2020, 2021, and 2022, are less than
the rates approved by CMS in Sections 40-26B-79 and 40-26B-80. (2) The Medicaid Agency makes
changes in its rules that reduce hospital inpatient payment rates, outpatient payment rates,
or adjustment payments, including any cost settlement protocol, that were in effect on September
30, 2019. (3) The inpatient or outpatient hospital access payments required...
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40-26B-20
Section 40-26B-20 Definitions. The following words, terms, and phrases shall have the
following meanings: (1) BED. Any bed that is licensed by the Alabama Department of Health
and its successor agency to provide nursing home care which is in a nursing facility. (2)
DEPARTMENT. The Department of Revenue of the State of Alabama. (3) FISCAL YEAR. An accounting
period of 12 months beginning on the first day of the first month of the state fiscal year.
(4) MEDICAID PROGRAM. The medical assistance program as established in Title XIX of the Social
Security Act and as administered in the State of Alabama by the Alabama Medicaid Agency pursuant
to executive order and Title 560 of the Alabama Administrative Code. (5) NURSING FACILITY.
An institution which is licensed under the laws of the State of Alabama as a skilled nursing
facility or an intermediate nursing facility. Nursing facility shall not include any facility
owned or operated by, or operating under an exclusive contract with, the State...
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38-9C-5
Section 38-9C-5 Providers who contract with agencies or programs required to develop
written policies to ensure rights. All providers who contract or subcontract with any federal,
state, or local agency or program to provide services in the State of Alabama to persons with
developmental disabilities or traumatic brain injury in Alabama shall develop and implement
written policies and procedures to ensure the rights enumerated above are observed by the
provider in discharging its contractual or subcontractual duties and responsibilities. At
a minimum, these policies and procedures shall provide for the following: (1) Affirm and safeguard
the rights stated in this chapter. (2) Provide that prompt, reasonable action be taken to
prevent the potential for further abuse while an investigation is in process. (3) Provide
for a prompt and thorough investigation of all allegations of abuse, exploitation, or neglect
by trained, experienced personnel delegated with all necessary authority. (4)...
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35-11-371
Section 35-11-371 Perfection of lien. (a) For the purposes of this section, the
following terms shall have the following meanings: (1) HEALTH CARE PAYOR. A health care insurer,
health maintenance organization, or health care service plan organized under Article 6, Chapter
20, Title 10A, authorized to provide health care coverage in the state. (2) SATISFY THE CLAIM.
Receipt by the hospital of either of the following: a. Full payment for services as billed.
b. If the hospital has a contract with the injured person's health care payor, payment together
with all credits, discounts, and contractual adjustments that the patient's bill would be
entitled under the contract, including recoupments, between the hospital and the patient's
health care payor which extinguish the patient's obligation for the services rendered. (b)
Unless specifically contrary to any contractual agreement between the hospital and the injured
person's health care payor or unless contrary to any statute or governmental...
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27-3A-3
Section 27-3A-3 Definitions. As used in this chapter, the following words and phrases
shall have the following meanings: (1) DEPARTMENT. The Alabama Department of Public Health.
(2) ENROLLEE. An individual who has contracted for or who participates in coverage under an
insurance policy, a health maintenance organization contract, a health service corporation
contract, an employee welfare benefit plan, a hospital or medical services plan, or any other
benefit program providing payment, reimbursement, or indemnification for health care costs
for the individual or the eligible dependents of the individual. (3) PROVIDER. A health care
provider duly licensed or certified by the State of Alabama. (4) UTILIZATION REVIEW. A system
for prospective and concurrent review of the necessity and appropriateness in the allocation
of health care resources and services given or proposed to be given to an individual within
this state. The term does not include elective requests for clarification of...
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25-5-312
Section 25-5-312 Powers and duties of the board. The board shall exercise general supervision
in all matters related to the provision of medical services provided by physicians, as defined
in Section 25-5-310, rendered to workers under this article. The duties of the board
shall include, but are not limited to, the following: (1) Study, develop, and implement any
necessary and reasonable guidelines for medical services and physician care provided by physicians.
In addition, with respect to services provided by physicians, the board shall study, develop,
and recommend to the secretary uniform medical criteria and policies for the conduct of utilization
review, bill screenings, and medical necessity determinations for use by insurance carriers,
self-insurers, and claims administrators. (2) Study, design, and implement standardized uniform
claims processing forms and forms for the reporting of medical information to employers and
insurance companies by physicians. (3) Address and give...
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25-5-290
Section 25-5-290 Ombudsman program, creation; purpose; members; notification of service;
benefit review conferences. (a) The Department of Industrial Relations shall establish an
Ombudsman Program to assist injured or disabled employees, persons claiming death benefits,
employers, and other persons in protecting their rights and obtaining information available
under the Workers' Compensation Law. (b) Providing that the employer and the employee agree
to participate in the benefit review conference, the ombudsmen shall meet with or otherwise
provide information to injured or disabled employees, investigate complaints, and communicate
with employers, insurance carriers, and health care providers on behalf of injured or disabled
employees. (c) Ombudsmen shall be Merit System employees and demonstrate familiarity with
the Workers' Compensation Law. An ombudsman shall not be an advocate for any person who shall
assist a claimant, employer, or other person in any proceeding beyond the...
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