22-6-159
Section 22-6-159 Implementation of article. (a) The following is the timeline for implementation of this article: (1) Not later than October 1, 2013, the Medicaid Agency shall establish Medicaid regions. (2) Not later than October 1, 2014, an organization seeking to become a regional care organization shall have established a governing board and structure as approved by the Medicaid Agency. An organization may receive probationary certification as a regional care organization upon submission of an application for, and demonstration of, a governing board acceptable to the Medicaid Agency. Probationary certification shall expire on October 1, 2016, or a later date established by the Medicaid Agency. (3) Not later than April 1, 2015, an organization with probationary regional care organization certification shall have demonstrated to Medicaid's approval the ability to establish an adequate medical service delivery network. (4) Not later than October 1, 2015, an organization with...
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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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22-6-227
Section 22-6-227 Quality assurance committee; reporting requirements. (a) The Medicaid Agency shall create a quality assurance committee appointed by the Medicaid Commissioner to review the care rendered through the integrated care networks. The members of the committee shall serve two-year terms. The Medicaid Agency shall promulgate a rule establishing the membership and criteria to serve on the quality assurance committee. (b) The Medicaid Agency shall continuously evaluate the outcome and quality measures adopted by the committee pursuant to this section. (c) The Medicaid Agency shall utilize available data systems for reporting outcome and quality measures adopted by the committee and take actions to eliminate any redundant reporting or reporting of limited value. (d) The Medicaid Agency shall publish the information collected under this section at aggregate levels that do not disclose information otherwise protected by law. The information published shall report all of the...
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22-6-200
Section 22-6-200 Federal financial participation; contract for services. This article shall be of no effect if federal financial participation under Title XIX of the Social Security Act is not available to the Medicaid program for the purposes of this article at the approved federal medical assistance percentage, established under Section 1905 of the Social Security Act, for the applicable fiscal year, or in the event a contract for services between the PACE program and the State of Alabama Medicaid Agency or Regional Care Organization is not executed by September 30, 2014, and by the end of each subsequent state fiscal year thereafter. (Act 2014-126, p. 236, ยง11.)...
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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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27-1-17.1
Section 27-1-17.1 Payment of providers through electronic funds transfer methods. (a) As used in this section, the following words shall have the following meanings: (1) ACH ELECTRONIC FUNDS TRANSFER. An electronic funds transfer through the Health Insurance Portability and Accountability Act (HIPPA) standard Automated Clearing House network. (2) COVERED HEALTH CARE PROVIDER. A physician as defined in Section 34-24-50.1; a dentist as defined in Section 34-9-1; a chiropractor as defined in Section 34-24-120; an individual engaged in the practice of optometry as defined in Section 34-22-1; other licensed health care professionals as defined in Title 34; a hospital as defined in Section 22-21-20; and a health care facility, or other provider who or that is accredited, licensed, or certified and who or that is performing within the scope of that accreditation, license, or certification. (3) HEALTH INSURANCE PLAN. Any hospital and medical expense incurred policy, health maintenance...
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27-56-2
Section 27-56-2 Definitions. As used in this chapter, the following terms shall have the following meanings: (1) COVERED PERSON. Any individual, family, or family member on whose behalf third-party payment or prepayment of health or medical expenses is provided under an insurance policy, plan, or contract providing for third-party payment or prepayment of health care or medical expenses. (2) EYE CARE PROVIDER. A licensed optometrist or a licensed ophthalmologist. (3) INSURANCE POLICY, PLAN, OR CONTRACT PROVIDING FOR THIRD-PARTY PAYMENT OR PREPAYMENT OF HEALTH OR MEDICAL EXPENSES. Includes an individual or group policy for accident or health insurance, an individual or group hospital or health care service contract, an individual or group health maintenance organization contract, an organized delivery system contract, or a preferred provider organization contract, and any other similar policy, plan, or contract. This term shall not include any employee welfare benefit plan, as defined...
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27-19A-12
Section 27-19A-12 Dental services - Coverages; fees; exceptions. (a) As used in this section, the following terms shall have the following meanings: (1) COVERED PERSON. Any individual, family, or family member on whose behalf third-party payment or prepayment of health or medical expenses is provided under an insurance policy, plan, or contract providing for third-party payment or prepayment of health care or medical expenses. (2) COVERED SERVICES. Dental care services for which a reimbursement is available under an enrollee's plan contract, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation. (3) DENTAL CARE PROVIDER. A licensed dentist. (4) DENTAL PLAN. Includes any policy of insurance which is issued by a health care service contractor which provides for coverage of...
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22-5A-4
Section 22-5A-4 Selection of community ombudsmen; training; certification; duties; area plan to describe program; notification of department as to prospective ombudsmen; advisory committee on program. (a) Each area agency on aging funded by the department shall select at least one community ombudsman in each planning and service area established according to regulations issued pursuant to the Older Americans Act of 1965, as amended. The community ombudsman shall be an employee or contractual employee of the area agency on aging and shall certify to having no association with any health care facility or provider for reward or profit. (b) The duties of each community ombudsman shall be as follows: (1) To receive, investigate, respond to, and attempt informally to resolve complaints made by or on behalf of recipients; (2) To report immediately instances of fraud, abuse, neglect, or exploitation to the department of pensions and security for investigation and follow-up pursuant to Chapter...
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41-5A-6
Section 41-5A-6 Chief examiner - Recovery audits for overpayments of state funds. (a) For the purposes of this section, the following words have the following meanings: (1) CHIEF EXAMINER. The Chief Examiner of Public Accounts. (2) OVERPAYMENT. Any payment in excess of amounts due and includes failure to meet eligibility requirements, failure to identify third party liability where applicable, any payment for an ineligible good or service, any payment for a good or service not received, duplicate payments, invoice and pricing errors, failure to apply discounts, rebates, or other allowances, failure to comply with contracts or purchasing agreements, or both, failure to provide adequate documentation or necessary signatures, or both, on documents, or any other inadvertent error resulting in overpayment. (3) RECOVERY AUDIT. A financial management technique used to identify overpayments made by a state agency with respect to individuals, vendors, service providers, and other entities in...
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