Ala. Admin. Code r. 560-X-50-.06

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

Section 560-X-50-.06 - Payment Acceptance

(1) The provider shall not charge Medicaid for services rendered on a no-cost basis to the general public except where such services are provided pursuant to Section 1903(c) of the Social Security Act or such services are provided by Title V Grantee pursuant to Section 1902(a)(11)(B) of the Social Security Act.

(2) Eligible Medicaid recipients are not to be billed for covered services once the recipient has been accepted as a Medicaid patient.

(3) It is the responsibility of the provider to follow-up with the fiscal agent or Medicaid on denied claims.

(4) The recipient is not responsible for any difference between billed charges and Medicaid allowed charges.

(5) The recipient may be billed for noncovered services.

(6) Preventive Health Education Services shall be billed on the HCFA 1500 claim form, utilizing locally assigned procedure codes. The appropriate ICD-9-CM diagnosis code shall be indicated on the claim form.

(7) Reimbursement to governmental agency providers will be based on a negotiated rate not to exceed actual costs as would occur through the efficient and economic operation by the provider. Reimbursement to nongovernmental providers will be based on Medicaid's established fee schedule, not to exceed the prevailing rate in the locality for comparable services offered under comparable conditions.

(8) Claims submitted for which there is no documentation, or for charges in excess or in violation of the provider's contractual agreement, are subject to recoupment by the agency, and to referral for investigation and possible prosecution for fraud.

Author: Dee Lockridge

Ala. Admin. Code r. 560-X-50-.06

Emergency rule effective December 11, 1991. Permanent rule effective March 13, 1992. Amended: Filed June 6, 1995; effective July 11, 1995.

Statutory Authority: State Plan for Medical Assistance; Title XIX, Social Security Act; 42 C.F.R. §447.15.