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22-6-192
Section 22-6-192 Definitions. For the purposes of this article, the following words have the
following meanings: (1) DEPARTMENT. The State Department of Revenue. (2) FISCAL YEAR. An accounting
period of 12 months beginning on the first day of the first month of the state fiscal year.
(3) 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 Medicaid Agency pursuant to
executive order and Title 560 of the Alabama Administrative Code. (4) PACE PROVIDER. PACE
means a provider under the federal Program for All Inclusive Care for the Elderly operated
by a public, private, nonprofit, or proprietary entity, as permitted by federal law as defined
at 42 C.F.R. §460.6, as amended and supplemented. (Act 2014-126, p. 236, §3.)...
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40-26B-70
Section 40-26B-70 Definitions. For purposes of this article, the following terms shall have
the following meanings: (1) ACCESS PAYMENT. A payment by the Medicaid program to an eligible
hospital for inpatient or outpatient hospital care, or both, provided to a Medicaid recipient.
(2) ALL PATIENT REFINED DIAGNOSIS-RELATED GROUP (APR-DRG). A statistical system of classifying
any non-Medicare inpatient stay into groups for the purposes of payment. (3) ALTERNATE CARE
PROVIDER. A contractor, other than a regional care organization, that agrees to provide a
comprehensive package of Medicaid benefits to Medicaid beneficiaries in a defined region of
the state pursuant to a risk contract. (4) CERTIFIED PUBLIC EXPENDITURE (CPE). A certification
in writing of the cost of providing medical care to Medicaid beneficiaries by publicly owned
hospitals and hospitals owned by a state agency or a state university plus the amount of uncompensated
care provided by publicly owned hospitals and hospitals...
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27-1-17
Section 27-1-17 Limitation periods for payment of claims; overdue claims; retroactive denials,
adjustments, etc.; penalties. (a) Each insurer, health service corporation, and health benefit
plan that issues or renews any policy of accident or health insurance providing benefits for
medical or hospital expenses for its insured persons shall pay for services rendered by Alabama
health care providers within 45 calendar days upon receipt of a clean written claim or 30
calendar days upon receipt of a clean electronic claim. If the insurer, health service corporation,
or health benefit plan is denying or pending the claim, the insurer, health service corporation,
or health benefit plan shall, within 45 calendar days for a written claim and 30 calendar
days for an electronic claim, notify the health care provider or certificate holder of the
reason for denying or pending the claim and what, if any, additional information is required
to process the claim. Any undisputed portion of the claim...
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25-5-1
Section 25-5-1 Definitions. Throughout this chapter, the following words and phrases as used
therein shall be considered to have the following meanings, respectively, unless the context
shall clearly indicate a different meaning in the connection used: (1) COMPENSATION. The money
benefits to be paid on account of injury or death, as provided in Articles 3 and 4. The recovery
which an employee may receive by action at law under Article 2 of this chapter is termed "recovery
of civil damages," as provided for in Sections 25-5-31 and 25-5-34. "Compensation"
does not include medical and surgical treatment and attention, medicine, medical and surgical
supplies, and crutches and apparatus furnished an employee on account of an injury. (2) CHILD
or CHILDREN. The terms include posthumous children and all other children entitled by law
to inherit as children of the deceased; stepchildren who were members of the family of the
deceased, at the time of the accident, and were dependent upon him or...
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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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16-47-240
Section 16-47-240 Alabama Rural Hospital Resource Center. (a) The University of Alabama at
Birmingham shall establish the Alabama Rural Hospital Resource Center. (b) The purpose of
the resource center is to facilitate access to high quality care for rural Alabamians and
improve their health by increasing the viability and capabilities of eligible hospitals at
no or minimal cost to those hospitals. (c) For the purposes of this section, the following
terms shall have the following meanings: (1) ELIGIBLE HOSPITAL. A nonprofit or public rural
hospital. (2) RESOURCE CENTER. The Rural Hospital Resource Center of the University of Alabama
at Birmingham. (3) RURAL. Located in one of the following: a. An area designated as a shortage
area as defined in 42 C.F.R. § 491.5(c) and (d); or b. A rural area as defined by the Federal
Office of Rural Health Policy. (d) The resource center shall do all of the following: (1)
Hire necessary staff that is inclusive and reflects the racial, gender,...
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40-26B-26
Section 40-26B-26 Reduction of revenues; reimbursement computations; quality incentive program.
THIS SECTION WAS AMENDED BY ACT 2020-147 IN THE 2020 REGULAR SESSION, EFFECTIVE MAY 18, 2020.
THIS IS NOT IN THE CURRENT CODE SUPPLEMENT. (a) No revenues resulting from the privilege assessment
established by this article and applied to increases in covered services or reimbursement
levels or other enhancements of the Medicaid program shall be subject to reduction or elimination
while the privilege assessment is in effect. (b) Every nursing facility participating in the
Medicaid program in the State of Alabama shall be reimbursed according to the reimbursement
methodology contained in Chapter 560-X-22 of the Alabama Medicaid Agency Administrative Code
(Supp. 12/31/95) on January 31, 1998, which methodology is incorporated by reference herein,
except that the following shall apply: (1) The ceiling for the operating cost center described
in Title 560-X-22-.06 (2)(a) of the Alabama Medicaid...
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21-3A-3
Section 21-3A-3 Definitions. The following words and phrases used in this chapter have the
following respective meanings unless the context clearly indicates otherwise: (1) COUNCIL.
The Interagency Coordinating Council as established in Section 21-3A-4. (2) EARLY INTERVENTION
SERVICES. Any developmental services that: a. Are provided under public supervision. b. Are
designed to meet the developmental needs of each eligible child and the needs of the family
related to enhancing the development of the child. c. Are selected in collaboration with the
parents. d. Are provided by qualified personnel as determined by the personnel standards of
the state, the standards of the early intervention program, and the regulations. e. Are provided
in conformity with an individualized family service plan. f. Meet the requirements of Public
Law 99-457 as amended (20 U.S.C. §§1471 to 1485, inclusive), and the early intervention
standards of the State of Alabama. g. Are provided, to the extent...
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13A-9-150
Section 13A-9-150 Public assistance fraud; penalties. (a) For the purposes of this section,
public assistance means money or property provided directly or indirectly to eligible persons
through programs of the federal government, the state, or any political subdivision thereof,
including any program administered by a public housing authority. (b) It shall be unlawful
for an individual or business entity to knowingly do any of the following: (1) Fail, by false
statement, misrepresentation, impersonation, or other fraudulent means, to disclose a material
fact used in making a determination as to the qualification of the person to receive public
assistance. (2) Fail to disclose a change in circumstances in order to obtain or continue
to receive any public assistance to which he or she is not entitled or in an amount larger
than that to which he or she is entitled. (3) Aid and abet another person in the commission
of the prohibitions enumerated in subdivisions (1) and (2). (4) Use,...
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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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