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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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27-1-21
Section 27-1-21 Uniformity of limits applied to fulfillment of certain drug prescriptions.
(a) For the purposes of this section, the following words shall have the following meanings:
(1) ENROLLEE. A person enrolled in a health benefit plan. (2) HEALTH BENEFIT PLAN. Any individual
or group plan, policy, or contract for health care services issued, delivered, issued for
delivery, renewed in this state by a health care insurer, health maintenance organization,
accident and sickness insurer, fraternal benefit society, nonprofit hospital service corporation,
nonprofit medical service corporation, health care service plan, or any other person, firm,
corporation, joint venture, or other similar business entity that pays for, purchases, or
furnishes health care services to patients, insureds, or beneficiaries in this state. The
term includes, but is not limited to, entities created pursuant to Article 6 of Chapter 4
of Title 10. The term shall not include any collective bargaining agreement...
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27-56-10
Section 27-56-10 Vision care providers - Contract requirements; rates; reimbursements; discounts.
(a) As used in this section, the following words shall have the following meanings: (1) CONTRACTUAL
DISCOUNT. A percentage reduction from a provider's usual and customary rate for covered services
and materials required under a participating provider agreement. (2) COVERED MATERIALS. Materials
for which reimbursement from the insurer or vision care plan is provided to a vision care
provider by an enrollee's plan contract, or for which a reimbursement would be available but
for the application of the enrollee's contractual limitations of deductibles, copayments,
or coinsurance. (3) COVERED SERVICES. Services for which reimbursement from the insurer or
vision care plan is provided to a vision care provider by an enrollee's plan contract, or
for which a reimbursement would be available but for the application of the enrollee's contractual
plan limitations of deductibles, copayments, or...
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27-57-1
Section 27-57-1 Definitions. As used in this chapter, the following words and terms shall have
the following meanings: (1) COLORECTAL CANCER EXAMINATIONS. Examinations and laboratory tests
specified in current American Cancer Society guidelines for colorectal cancer screening of
asymptomatic individuals. (2) HEALTH BENEFIT PLAN. A group health insurance policy that covers
hospital, medical, or surgical expenses, health maintenance organizations, preferred provider
organizations, medical service organizations, physician-hospital organizations, or any other
person, firm, corporation, joint venture, or other similar business entity that pays for,
purchases, or furnishes health care services to patients, insureds, or beneficiaries in this
state. For the purposes of this chapter, a health benefit plan located or domiciled outside
of the State of Alabama is deemed to be subject to this chapter if it receives, processes,
adjudicates, pays, or denies claims for health care services submitted...
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27-57-5
Section 27-57-5 Coverage by participating providers; selection criteria and utilization protocols;
maximum benefits, exclusions, etc. (a) This chapter does not require and shall not be construed
to require the coverage of services of providers who are not designated as covered providers,
or who are not selected as a participating provider, by a group health benefit plan or insurer
having a participating network of service providers. Nothing in this chapter is intended to
expand the list or designation of participating providers as specified in any health benefit
plan. (b) Insurers or other issuers of any health benefit plan covered by this chapter shall
continue to be able to establish and apply selection criteria and utilization protocols for
health care providers including the designation of types of providers for which coverage is
provided as well as credentialing criteria used in the selection of providers. (c) A group
health benefit plan, policy, or contract that provides coverage...
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22-6-11
Section 22-6-11 Breast and cervical cancer prevention and treatment. (a) This section shall
be known and may be cited as the "2009 Breast and Cervical Cancer Prevention and Treatment
Act." (b)(1) Medicaid eligibility and coverage shall be extended to a woman who has been
determined to be eligible to participate in and has been screened for breast or cervical cancer
by any health care provider or entity, or both, that satisfies any of the following: a. Receives
direct payment for screening services by National Breast and Cervical Cancer Early Detection
Program (NBCCEDP) Title XV funds. b. Is funded at least in part by NBCCEDP grantee Title XV
funds for screening services. c. Is not funded at all by NBCCEDP grantee Title XV funds but
has been identified by the Department of Public Health as part of the Alabama Breast and Cervical
Cancer Early Detection Program and operates consistently within its guidelines. (2) Coverage
under this section shall be limited to any woman screened and...
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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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27-54A-2
Section 27-54A-2 Treatment under certain policies and contracts. (a) As used in this section,
the following words have the following meanings: (1) APPLIED BEHAVIOR ANALYSIS. The design,
implementation, and evaluation of environmental modifications, using behavioral stimuli and
consequences, to produce socially significant improvement in human behavior, including the
use of direct observation, measurement, and functional analysis of the relationship between
environment and behavior. (2) AUTISM SPECTRUM DISORDER. Any of the pervasive developmental
disorders or autism spectrum disorders as defined by the most recent edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or the edition that was in effect at the
time of diagnosis. (3) BEHAVIORAL HEALTH TREATMENT. Counseling and treatment programs, including
applied behavior analysis that are both of the following: a. Necessary to develop, maintain,
or restore, to the maximum extent practicable, the functioning of an...
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22-8A-9
Section 22-8A-9 Withholding or withdrawal of treatment, etc., not suicide; execution of advance
directive not to affect sale, etc., of life or health insurance nor be condition for receipt
of treatment, etc.; provisions of chapter cumulative. (a) The withholding or withdrawal of
life-sustaining treatment or artificially provided nutrition and hydration from a patient
in accordance with the provisions of this chapter shall not, for any purpose, constitute a
suicide and shall not constitute assisting suicide. (b) The making of an advance directive
for health care pursuant to this chapter shall not affect in any manner the sale, procurement,
or issuance of any policy of life or health insurance, nor shall it be deemed to modify the
terms of an existing policy of life or health insurance. No policy of life or health insurance
shall be legally impaired or invalidated in any manner by the withholding or withdrawal of
life-sustaining treatment or artificially provided nutrition and hydration...
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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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