Ala. Admin. Code r. 560-X-57-.06

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

Section 560-X-57-.06 - Application Process

(1) The case manager will receive referrals from hospitals, nursing homes, physicians, the community and others for persons who may be eligible for home and community-based services. For institutional residents residing in a facility for at least 90 days who are interested in transitioning into the community, the case manager should thoroughly review referrals and intake information. This process will take place during the 180 consecutive day transition period.

(2) An initial assessment will be completed by the case manager in conjunction with the applicant's physician. This document will reflect detailed information regarding social background, living conditions, and medical problems of the applicant. A copy of this document will be submitted to the operating agency, Alabama Department of Rehabilitation Services (ADRS), for approval.

(3) The case manager, in conjunction with the applicant's physician, client and/or caregiver will develop a PCCP. The PCCP will include objectives, services, provider of services, and frequency of service. Changes to the original PCCP are to be made as needed to adequately care for an individual. Reasons for changes must be documented on the client's care plan which is subject to the review of the Alabama Medicaid Agency. The PCCP must be reviewed by the case manager as often as necessary and administered in coordination with the recipient's physician.

(4) The Alabama Medicaid Agency has delegated the medical level of care determination to qualified trained individuals at ADRS.

(5) Medicaid requires the providers to submit an application in order to document dates of service provision to long term care recipients.

(a) The long-term care file maintains these dates of service.

(b) The applications will be automatically approved through systematic programming.

(c) The Alabama Medicaid Agency will perform random audits on a percentage of records to ensure that documentation supports the medical level of care criteria, physician certification, as well as other state and federal requirements.

(6) ADRS is responsible for the assessment, evaluation of admissions, readmissions, and annual redeterminations for eligible participants receiving home and community-based services in accordance with the provisions of the SAIL Waiver.

(7) The Alabama Medicaid Agency will provide to ADRS the approved Level of Care criteria and policies and procedures governing the level of care determination process.

(8) ADRS will designate a qualified medical professional to approve the level of care and develop the PCCP.

(9) Admissions, readmissions and annual redeterminations must be certified by a physician licensed to practice in Alabama.

(10) ADRS may utilize Medicaid staff for consultation on questionable admissions and annual redeterminations prior to a final decision being rendered.

(11) The Alabama Medicaid Agency will conduct a monthly retrospective review of a random sample of individuals served under the SAIL Waiver to determine appropriate admissions and annual redeterminations. This review includes whether appropriate documentation is present and maintained and whether all state and federal medical necessity and eligibility requirements for the program are met.

(12) The Alabama Medicaid Agency will initiate recoupment of payment for services when it determines that state and federal, medical necessity, and eligibility requirements are not met.

(13) The Alabama Medicaid Agency may seek recoupment from ADRS for other services reimbursed by Medicaid for those individuals whom Medicaid determines would not have been eligible for SAIL Waiver services or Medicaid eligibility but for the certification of waiver eligibility by ADRS.

Ala. Admin. Code r. 560-X-57-.06

Emergency rule effective April 1, 1992. Permanent rule effective June 12, 1992. Amended: September 6, 1996; effective October 12, 1996. Amended: Filed June 11, 2003; effective July 16, 2003. Amended: Filed July 17, 2003; effective August 21, 2003. Amended: Filed March 14, 2007; effective April 18, 2007. Amended: Filed August 11, 2008; effective September 15, 2008.

Amended by Alabama Administrative Monthly Volume XXXIX, Issue No. 01, October 30, 2020, eff. 12/14/2020.

Author: Antionette Hardy, Administrator, LTC Healthcare Reform Unit

Statutory Authority:42 C.F.R. § 441, Subpart G and the Homebound Waiver.