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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
persons, firms, or corporations claimed by the injured person, or the legal representative
of the person, to be liable for damages arising from the injuries. The claimant shall also
within one day after the filing of the claim or lien, mail a copy thereof by registered or
certified mail, postage prepaid, for each person, firm, or corporation so claimed to be liable
on account of the injuries, at the addresses so given in the statement, and to the patient,
his or her guardian, or his or her personal representative at the address given at
the time of admission. (d) The filing of a claim or lien shall be notice thereof to all persons,
firms, or corporations liable for damages, whether or not they are named in the claim or lien.
Nothing shall be deemed to preclude the hospital from perfecting its lien outside of the time
limits stated in this section through providing actual notice to persons, firms, or corporations.
(e) The judge of probate shall endorse thereon the date and hour of...
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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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