Ala. Admin. Code r. 560-X-17-.05

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

Section 560-X-17-.05 - Billing Procedures

(1) All claims for payment of services rendered, filed by ophthalmologists, optometrists, and opticians are to be billed on appropriate form provided by the fiscal agent.

(2) Claims are to be forwarded directly to the Medicaid fiscal agent for payment within one year of the date of service. The Medicaid Provider Manual contains information on claims processing.

(3) A claim for payment may be submitted for a cancelled order.

(4) Eye Examination Only.

(a) The claim should specify "Complete Eye Examinations and Refraction."

(b) If services other than a "complete examination" are provided, the claim should reflect the appropriate optometric procedure code. This claim should be sent directly to the Medicaid fiscal agent. This claim should be sent directly to the Medicaid fiscal agent.

(5) Medical Condition and Treatment. The claim should be sent directly to the Medicaid fiscal agent.

(6) Eye Examination (Including Refraction) and Fitting (Including Frame Service, Verification, and Subsequent Service) all by the same provider when eyeglasses are procured from the central Medicaid source contractor:

(a) Claims are to be sent directly to the Medicaid fiscal agent.

(b) The claim will separately identify the extent of the examination, refraction and fitting. Lenses and frames are not to be billed by the practitioner.

(c) The Medicaid job order form reflecting all necessary prescription data including frame required will be forwarded to Central Medicaid Source Contractor to fill the prescription, and return the eyeglasses to the examiner for delivery to the patient. Patient or Authorized Signature box will contain appropriate signature, or the statement "Signature on file."

(d) The Central Medicaid Source Contractor will submit claims for payment to the fiscal agent.

(7) When eyeglasses are NOT procured from the Central Medicaid Source Contractor.

(a) The claim should separately specify the extent of the examination performed refraction, fitting, lenses, and frame.

(b) When Opticians provide eyeglasses the claim should only identify the fitting service, lenses and frame.

(c) The claim is sent directly to the fiscal agent. Reimbursement for lenses and frames will be at the central source contract prices.

(8) Fitting (Including Frame Service, Verification, and Subsequent Service) only, when eyeglasses are procured from the central Medicaid Source Contractor:

(a) The claims are to be sent for payment directly to the Medicaid fiscal agent.

(b) The claim will specify the fitting services only.

(9) Additional billing instructions will be published, as the need arises by the Medicaid fiscal agent.

(10) An Alabama Medicaid Provider may bill an Alabama Medicaid recipient when the recipient has exhausted all of his/her allowed Medicaid benefits for the calendar year, or when the service rendered by the provider is a noncovered benefit as outlined in the Alabama Medicaid Agency Administrative Code.

(a) Conditional collections to be refunded post payment by Medicaid and partial charges for balance of Medicaid allowed reimbursement are prohibited.

(11) Ophthalmologists and optometrists are required to collect and it is the Medicaid recipient's responsibility to pay the maximum designated co-payment amount for each service rendered. This includes patients with Medicare.

(a) A provider agrees to accept as payment in full the amount paid by the state, plus any cost-sharing amount to be paid by the recipient, for covered items, and further agrees to make no additional charge(s) for covered items to the recipient, sponsor, or family of the recipient, except the appropriate allowable co-payment amount.

Ala. Admin. Code r. 560-X-17-.05

Rule effective October 1, 1982. Amended: effective July 9, 1984; June 8, 1985; January 13, 1988; March 13, 1993.

Authors: Charles A. Reasner, Andy W. Beckham, R. Dale Boyles.

Statutory Authority: State Plan, Attachment 4.18-a; Title XIX, Social Security Act; 42 C.F.R. §§ 401, etseq.; 447.15.