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22-6-8
Section 22-6-8 Revocation of eligibility of recipient upon determination of abuse, fraud, or
misuse of benefits; when eligibility may be restored; award of restricted status to pregnant
recipient whose eligibility has been revoked. (a) Upon determination by a utilization review
committee of the designated State Medicaid Agency that a Medicaid recipient has abused, defrauded,
or misused the benefits of the program said recipient shall immediately become ineligible
for Medicaid benefits. (b) Medicaid recipients whose eligibility has been revoked due to abuse,
fraud or other deliberate misuse of the program shall not be deemed eligible for future Medicaid
services for a period of not less than one year and until full restitution has been made to
the designated State Medicaid Agency. (c) When a Medicaid recipient, whose eligibility has
been revoked due to abuse, fraud, or other deliberate misuse of the program, reapplies for
coverage during the period of suspension due to pregnancy, the...
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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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22-18-50
Section 22-18-50 Enactment and text of Emergency Medical Services Personnel Licensure Interstate
Compact. The Emergency Medical Services Personnel Licensure Interstate Compact is hereby enacted
into law and entered into with all other jurisdictions legally joining therein in form substantially
as follows: SECTION 1. PURPOSE In order to protect the public through verification of competency
and ensure accountability for patient care related activities all states license emergency
medical services (EMS) personnel, such as emergency medical technicians (EMTs), advanced EMTs
and paramedics. This Compact is intended to facilitate the day to day movement of EMS personnel
across state boundaries in the performance of their EMS duties as assigned by an appropriate
authority and authorize state EMS offices to afford immediate legal recognition to EMS personnel
licensed in a member state. This Compact recognizes that states have a vested interest in
protecting the public's health and safety...
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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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22-6-123
Section 22-6-123 Considerations for inclusions on preferred drug list; review; adoption of
list. (a) Drugs will be considered for the Medicaid preferred drug list based on clinical
efficacy, side effect profiles, appropriate usage, and cost effectiveness. (b) The Medicaid
Pharmacy and Therapeutics Committee shall perform a thorough review of relevant clinical and
medical considerations, including, but not limited to: Medicaid Drug Utilization Review (DUR)
data; Surveillance Utilization Review (SUR) data; potential abuse, misuse, or inappropriate
use in prescribing and/or dispensing patterns; inconsistency with FDA approved labeling, inconsistency
with uses recognized in the American Hospital Formulary Service Drug Information, and the
American Medical Association Drug Evaluations, or the U.S. Pharmacopoeia Dispensing Information.
(c) The Medicaid Pharmacy and Therapeutics Committee shall recommend and the Medicaid Agency
shall adopt an initial Medicaid preferred drug list not later...
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22-6-9
Section 22-6-9 Medicaid identification card; issuance and use; confidentiality of recipient.
(a) The Department of Human Resources shall issue to all eligible recipients a special color
picture medicaid identification card, which shall be separate from and entirely distinct from
the valid color picture driver license or non-driver identification card. The Medicaid identification
card shall be issued only on presentation of proper identification and evidence of medicaid
eligibility. The identification card shall be used as identification to providers of medical
service, and the identification card shall contain a suitable medium which when used with
a suitable data processing system, to be developed by the Department of Human Resources with
the technical assistance and advice of the Alabama Criminal Justice Information Center, can
provide real-time verification of Medicaid eligibility by the provider. (b) The Department
of Human Resources shall make provision for adequate protection of...
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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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27-21A-3
Section 27-21A-3 Issuance of certificate of authority. (a)(1) Upon receipt of an application
for issuance of a certificate of authority, the commissioner shall forthwith transmit copies
of such application and accompanying documents to the State Health Officer. (2) The State
Health Officer shall determine whether the applicant for a certificate of authority, with
respect to health care services to be furnished: a. Has demonstrated the willingness and potential
ability to assure that such health care services will be provided in a manner to assure both
availability and accessibility of adequate personnel and facilities and in a manner enhancing
availability, accessibility, and continuity of service; b. Has arrangements, established in
accordance with the regulations promulgated by the State Health Officer, for an on-going quality
assurance program concerning health care processes and outcomes; and c. Has a procedure, established
in accordance with regulations of the State Health...
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22-21-264
Section 22-21-264 Criteria for state agency review. The SHPDA, pursuant to the provisions of
Section 22-21-274, shall prescribe by rules and regulations the criteria and clarifying definitions
for reviews covered by this article. These criteria shall include at least the following:
(1) Consistency with the appropriate State Health Facility and services plans effective at
the time the application was received by the State Agency, which shall include the latest
approved revisions of the following plans: a. The most recent Alabama State Health Plan which
shall include updated inventories and separate bed need methodologies for inpatient rehabilitation
beds, inpatient psychiatric beds and inpatient/residential alcohol and drug abuse beds. b.
Alabama State Health Plan for services to the mentally ill. c. Alabama State Plan for rehabilitation
facilities. d. Alabama developmental disabilities plan. e. Alabama State alcoholism plan.
f. Such other State Plans as may from time to time be...
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