Ala. Admin. Code r. 560-X-4-.01

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

Section 560-X-4-.01 - General

(1) The Program Integrity Division is responsible for planning, developing, and directing Agency efforts to identify, prevent, and prosecute fraud, waste and/or abuse in the Medicaid Program. This includes verifying that medical services are appropriate and rendered as billed, that services are provided by qualified providers to eligible recipients, that payments for those services are correct, and that all funds identified for collection are pursued.

(2) Federal regulations require the State Plan for Medical Assistance to provide for the establishment and implementation of a statewide surveillance and utilization control program that safeguards against unnecessary or inappropriate utilization of care and services and excess payments. The Alabama Medicaid Agency (Medicaid) has designated the Program Integrity Division to perform this function. The division is responsible for detecting fraud, waste, and/or abuse within the Medicaid Program through reviewing paid claims history, reviewing provider and recipient enrollment applications, and conducting field reviews and investigations to determine provider/recipient abuse, waste, and suspicion of fraud. In addition, the division is utilized to aid in program management and system improvement to prevent fraud, waste and/or abuse in the Medicaid Program.

(3) Cases of suspected recipient fraud are referred to local law enforcement authorities for prosecution upon completion of investigation. Cases of a credible allegation of provider fraud and nursing home patient account abuse are referred, upon completion of a preliminary investigation, to the Medicaid Fraud Control Unit in the Alabama Attorney General's Office which was established under Public Health 95-142 and Health and Human Services guidelines to conduct full investigations for possible prosecution, alleged provider fraud and nursing home patient account abuse in the Medicaid Program.

(4) The Utilization Review Committee (URC) is established under the authority of Code of Alabama (1975) Section 22-6-8. This Committee reviews cases of suspected provider or recipient fraud or abuse and recommends appropriate sanctions. (Refer to sections 560-X-4-.04 and 560-X-4-.05 )

Ala. Admin. Code r. 560-X-4-.01

Rule effective October 1, 1982. Amended effective November 10, 1988. Repealed and Replaced: Filed February 7, 1994; effective March 15, 1994.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 12, September 28, 2018, eff. 10/26/2018.

Author: Jacqueline G. Thomas, Director, Program Integrity Division

Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. Parts 431, 455, 456, 1000, 1001, 1001, 1002, State Medical Manual 11420.6M.