Ala. Admin. Code r. 480-5-5-.30

Current through Register Vol. 43, No. 1, October 31, 2024

Section 480-5-5-.30 - Home Health Care Service

(1) Prior to the provision of medical services, supplies or other non-medical services, the determination that the illness, injury or condition is work related must be made and shall be pre-certified as medically necessary and not for the convenience of the patient and/or family.

(a) All nursing services and personal care services shall have prior authorization by the employer/agent.

(b) A description of needed nursing or other attendant services, as well as specifying the level of nursing care (R.N., L.P.N., sitter/nonprofessional), shall be included in the request for authorization.

(2) Nursing care by a registered nurse or licensed practical nurse and personal care by an attendant may be covered services when ordered by the authorized treating physician.

(3) Payment may be made for authorized services to the following provider types, subject to the following guidelines:

(a) Trained professional nursing personnel who provide services through the auspices of public or private home health agencies who are paid for their services by their employer.

(b) Nursing manpower agencies and home health agencies shall be reimbursed using the Maximum Fee Schedule for Home Health Agencies or any mutually agreed reimbursement pursuant to Code of Ala. 1975, § 25-5-314.

(c) Authorized services by nonprofessional family members are reimbursable up to eight (8) hours in any 24-hour period. Any family member who is a medical professional may provide services under the same restrictions placed on self-employed nurses and attendants.

(d) Trained professional nursing personnel who are, self-employed may be paid directly for their services at a rate not to exceed the Maximum Fee Schedule for Home Health Agencies. Self-employed nurses and attendants are considered independent contractors; therefore, the employer/agent takes no responsibility for producing income tax forms for those individuals.

(e) Family members and other persons who are not trained professional nursing personnel may receive payment in the amount of the current minimum wage if the following requirements have been satisfied:

1. The attendant has received adequate instruction from the authorized treating provider regarding the services to be provided in the home;

2. The services provided must be beyond the scope of the normal household duties and must be in the nature of services ordinarily rendered by trained professional personnel in hospitals or nursing homes; and

3. The medical necessity justification shall be sufficient to identify the nature and approximate value of the services provided.

(f) The purpose of private duty nurses is to provide skilled constant attention and observation to a seriously ill patient. The need for, and the length of, service usually depends on the condition of the patient and the level of care required rather than the nature of the disease, illness or injury.

(g) Patients recovering from major surgery, severe systemic disease or one of the catastrophic diseases, frequently require a level of skilled care beyond that afforded by the general nursing services provided by a hospital or other institution.

(h) If an injured worker is receiving treatment for both compensable and noncompensable medical conditions, only those services provided in treatment of compensable conditions shall be listed on claims and invoices submitted to the employer/agent. In addition, payments from private payers for noncompensable conditions shall not be listed on claims submitted to the employer/agent.

(4) Reimbursement shall be made for the lesser of:

(a) The provider's usual and customary fee;

(b) The Maximum Fee Schedule for Home Health Agencies; or

(c) Mutually agreed upon reimbursement pursuant to Code of Ala. 1975, § 25-5-314.

(5) In computing the number of visits rendered an injured worker for compensable benefits, each personal contact in the residence of the injured worker for the purpose of providing covered services by a home health agency employee or by others under contract or arrangement with the home health agency shall be counted as a visit. A visit made simultaneously by two or more workers from a home health agency to provide a single covered service for which one supervises or instructs the other shall be counted as one visit.

Author: Workers' Compensation Division

Ala. Admin. Code r. 480-5-5-.30

New Rule: Filed August 9, 1996; effective September 13, 1996.

Statutory Authority:Code of Ala. 1975, § 25-5-293.