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34-23-183
Section 34-23-183 Application. This article shall apply to any audit of the records
of a pharmacy conducted by a managed care company, nonprofit hospital or medical service organization,
health benefit plan, third-party payor, pharmacy benefit manager, a health program administered
by a department of the state, except the Alabama Medicaid Agency, or any entity that represents
those companies, groups, or department. (Act 2012-306, p. 668, §4; Act 2018-457, §1.)...
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34-23-184
Section 34-23-184 Audit procedures; report. (a) The entity conducting an audit shall
follow these procedures: (1) The pharmacy contract shall identify and describe in detail the
audit procedures. (2) The entity conducting the on-site audit shall give the pharmacy written
notice at least two weeks before conducting the initial on-site audit for each audit cycle.
If the pharmacy benefit manager does not include their auditing guidelines within their provider
manual, then the notice must include a documented checklist of all items being audited and
the manual, including the name, date, and edition or volume, applicable to the audit and auditing
guidelines. For on-site audits a pharmacy benefit manager shall also provide a list of material
that is copied or removed during the course of an audit to the pharmacy. The pharmacy benefit
manager may document this material on either a checklist or on an audit acknowledgement form.
The pharmacy shall produce any items during the course of the...
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34-23-181
Section 34-23-181 Definitions. The following words shall have the following meanings
as used in this article: (1) HEALTH BENEFIT PLAN. Any individual or group plan, employee welfare
benefit plan, policy, or contract for health care services issued, delivered, issued for delivery,
or 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 insureds or beneficiaries in
this state. The term includes, but is not limited to, entities created pursuant to Article
6 of Chapter 20 of Title 10A. A health benefit plan located or domiciled outside of the State
of Alabama is deemed to be subject to this article if it receives, processes, adjudicates,
pays, or denies claims for health care services submitted by or...
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20-2-213
Section 20-2-213 Reporting requirements. (a) Each of the entities designated in subsection
(b) shall report to the department, or to an entity designated by the department, controlled
substances prescription information as designated by regulation pertaining to all Class II,
Class III, Class IV, and Class V controlled substances in such manner as may be prescribed
by the department by regulation. (b) The following entities or practitioners are subject to
the reporting requirements of subsection (a): (1) Licensed pharmacies, not including pharmacies
of general and specialized hospitals, nursing homes, and any other health care facilities
which provide inpatient care, so long as the controlled substance is administered and used
by a patient on the premises of the facility. (2) Mail order pharmacies or pharmacy benefit
programs filling prescriptions for or dispensing controlled substances to residents of this
state. (3) Licensed physicians, dentists, podiatrists, or optometrists who...
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41-15B-2.2
Section 41-15B-2.2 Allocation of trust fund revenues. (a) For each fiscal year, beginning
October 1, 1999, contingent upon the Children First Trust Fund receiving tobacco revenues
and upon appropriation by the Legislature, an amount of up to and including two hundred twenty-five
thousand dollars ($225,000), or equivalent percentage of the total fund, shall be designated
for the administration of the fund by the council and the Commissioner of Children's Affairs.
(b) For the each fiscal year, beginning October 1, 1999, contingent upon the Children First
Trust Fund receiving tobacco revenues, the remainder of the Children First Trust Fund, in
the amounts provided for in Section 41-15B-2.1, shall be allocated as follows: (1)
Ten percent of the fund shall be allocated to the Department of Public Health for distribution
to one or more of the following: a. The Children's Health Insurance Program. b. Programs for
tobacco control among children with the purpose being to reduce the consumption...
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27-14-11.1
Section 27-14-11.1 Contents of policies - Denial or reduction of benefits due to Medicaid
eligibility void. (a) For purposes of this section, "private insurer" is
defined as any of the following: (1) Any commercial insurance company offering health or casualty
insurance to individuals or groups, including both experience-rated contracts and indemnity
contracts. (2) Any profit or nonprofit prepaid plan offering either medical services or full
or partial payment for the diagnosis or treatment of an injury, disease, or disability. (3)
Any organization administering health or casualty insurance plans for professional associations,
unions, fraternal groups, employer-employee benefit plans, and any similar organization offering
these payments or services, including self-insured and self-funded plans. (4) Any health insurer,
including group health plans, as defined in Section 607(1) of the Employee Retirement
Income Security Act of 1974, self-insured plans, service benefit plans, managed care...
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22-50-1
Section 22-50-1 Definitions. For the purposes of this chapter, the following terms shall
have the meanings respectively ascribed to them by this section: (1) CLIENTS. Those
persons identified as receiving or needing services for an intellectual disability. (2) DEPARTMENT.
The Department of Mental Health. (3) INTELLECTUAL DISABILITY SERVICES. Evaluation for, amelioration
of, habilitation for, prevention of, and research into the causes of intellectual disability.
(4) MENTAL HEALTH SERVICES. Diagnosis of, treatment of, rehabilitation for, follow-up care
of, prevention of and research into the causes of all forms of mental or emotional illness,
including, but not limited to, alcoholism, drug addiction, or epilepsy in combination with
mental illness or an intellectual disability. (5) MENTAL ILLNESS OR SUBSTANCE ABUSE TREATMENT.
The application of professionally planned, managed, administered, or monitored clinical procedures
or evidenced-based interventions to identify, stabilize,...
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27-1-19
Section 27-1-19 Reimbursement of health care providers. (a) The insured, or health or
dental plan beneficiary may assign reimbursement for health or dental care services directly
to the provider of services. Health benefits include medical, pharmacy, podiatric, chiropractic,
optometric, durable medical equipment, and home care services. The company or agency, when
authorized by the insured, or health or dental plan beneficiary, shall pay directly to the
health care provider the amount of the claim, under the same criteria and payment schedule
that would have been reimbursed directly to the contract provider, and any applicable interest.
This amount only applies to assigned claims. Any company or agency making a payment to the
insured, or health or dental plan beneficiary, after the rights of reimbursement have been
assigned to the provider of services, shall be liable to the provider for the payment. If
the company or agency fails to reimburse the provider in accordance with the terms...
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27-12A-1
Section 27-12A-1 Definitions. As used in this chapter, the following terms shall have
the following meanings: (1) COMMISSIONER. The Alabama Commissioner of Insurance or his or
her designee. (2) DEPARTMENT. The Alabama Department of Insurance. (3) INSURANCE. As defined
in Section 27-1-2, and specifically including any contract, arrangement, or agreement,
in which one undertakes to do any one of the following: a. Pay or indemnify another as to
loss from certain contingencies called risks. b. Pay or grant a specified amount or determinable
benefit to another in connection with ascertainable risk contingencies. c. Pay an annuity
to another. d. Act as surety. For the purposes of this chapter, insurance also includes any
health benefit plan as defined in Section 27-53-1. (4) INSURANCE PRODUCER or PRODUCER.
As defined in Section 27-7-1. (5) INSURER. A person entering into agreements, contracts
of insurance, arrangements, or reinsurance, or a health benefit plan, or a group health plan
as...
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27-1-20
Section 27-1-20 Patient Right to Know Act. (a) This section shall be known and
may be cited as the "Patient Right to Know Act." (b) As used in this section,
unless the context clearly indicates otherwise, the following words shall have the following
meanings: (1) ENROLLEE. A person who purchases individual health care coverage or an employer
who purchases a group health care plan. (2) PROVIDER. A physician, dentist, podiatrist, pharmacist,
optometrist, psychologist, clinical social worker, advanced nurse practitioner, registered
optician, licensed professional counselor, physical therapist, and chiropractor. (c)(1) All
persons, firms, corporations, associations, health maintenance organizations, health insurance
services, or preferred provider organizations, any employer-sponsored health benefit plan,
or any similar organization or entity, providing health, accident, or dental insurance coverage,
either directly or indirectly, shall provide an enrollee with a written description of the...
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