Ala. Admin. Code r. 560-X-6-.02

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

Section 560-X-6-.02 - Submission Of Claims: General

(1) Effective March 1, 2010, all claims that do not require attachments (TPL denial), manual review (unclassified J codes), and an Administrative Review override by Medicaid or additional information to be printed on the claim (Work Incentive Program) must be submitted electronically to the Alabama Medicaid Agency fiscal agent. All paper claims received by the Alabama Medicaid Agency fiscal agent which do not meet the above requirements will be returned to the provider without being processed. Paper claims meeting the requirements should be submitted on CMS-1500 (Health Insurance Claim) forms. Each claim filed by a physician constitutes a contract with Medicaid.

(2) For claim filing limitations, refer to Chapter 1, Rule 560-X-1-.17.

(3) Physicians who want to participate in the Alabama Medicaid Program must be enrolled and receive a provider number.

(4) Claims must include the name and NPI number of the physician who takes responsibility for the services. The NPI number must identify the responsible individual, not a group or institution. Reimbursement may be made to a physician submitting a claim for services furnished by another physician in the event there is a reciprocal arrangement. The regular physician shall identify the services as substitute physician services by entering HCPCS modifier Q5 (Service Furnished by a Substitute Physician under a Reciprocal Arrangement) or HCPCS modifier Q6 (Service Furnished by a Locum Tenens Physician) after the procedure code. The substitute physician must be enrolled with Medicaid as an active provider. The reciprocal arrangement may not exceed 14 continuous days in the case of an informal arrangement or 60 continuous days in the case of an arrangement involving per diem or other fee-for-time compensation. The regular physician should keep a record on file of each service provided by the substitute physician and make this record available to Medicaid upon request. Payment may not be made for services provided by providers who have been suspended or terminated from participation in the Medicaid program. See Rule No. 560-X-4-.04 for details. Claims will be subject to post-payment review. Refer to the Alabama Medicaid Provider Manual, Chapter 28 for information regarding modifiers Q5 and Q6.

(5) Incomplete or inaccurate claim forms submitted for processing will be returned to the provider by the Medicaid fiscal agent for the necessary information.

(6) Before submitting a claim, a careful check should be made to see that the Medicaid identification number agrees with the number and exact spelling of the name on the patient's plastic Medicaid eligibility card.

(7) In filling out claim forms, providers must use diagnosis codes from the ICD-9-CM diagnosis codes (dates of services prior and up to September 30, 2015) or ICD-10-CM diagnosis codes (dates of services October 1, 2015 and forward) and procedures codes from the CPT Code Book, or approved procedures codes designated by Medicaid.

(8) Factoring arrangements in connection with the payment of claims under Medicaid are prohibited.

(9) Medicaid's fiscal agent will furnish to new providers a manual containing billing instructions.

(10) Pharmacists must have the physician's license number prior to billing for prescriptions. Refer to Chapter 16.

(11) Fragmentation of procedures, including laboratory procedures, under the Medicaid program is prohibited.

Ala. Admin. Code r. 560-X-6-.02

Rule effective October 1, 1982. Amended effective March 12, 1984; November 11, 1985; March 12, 1987. Emergency rule effective April 1, 1991. Amended effective July 13, 1991; October 13, 1992. Amended: Filed February 7, 1994; effective March 15, 1994. Amended: Filed December 7, 1994; effective January 12, 1995. Amended: Filed May 10, 2002; effective June 14, 2002. Amended: Filed May 11, 2012; effective June 15, 2012.

Amended by Alabama Administrative Monthly Volume XXXIV, Issue No. 04, January 29, 2016, eff. 2/25/2016.

Author: Beverly Churchwell; Program Manager; Medical Support

Statutory Authority: Title XIX, Social Security Act; 42 C.F.R. §§401, etseq.; State Plan; Omnibus Budget Reconciliation Act of 1990 (Public law 1051508).