Ala. Admin. Code r. 560-X-6-.12

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

Section 560-X-6-.12 - Covered Services: General

(1) In general, physician services are covered by Medicaid if the services are:

(a) Considered medically necessary by the attending physician. However, when the persons designated responsible for utilization review have issued a denial for inpatient days, no ancillary charge or professional charges will be reimbursed during the denied period.

(b) Designated by procedure codes in Physicians' Current Procedural Terminology (CPT), or designated by special procedure codes created by Medicaid for its own use.

(2) Physicians will not be paid for and should not submit claims for laboratory work done for them by independent laboratories or by hospital laboratories. Physicians may submit claims for laboratory work done by them in their own offices or own laboratory facilities. For specific information concerning the "professional component" and drawing and extraction reimbursement, see the laboratory chapter.

(3) If a physician is not sure whether a service is covered, that physician can contact the Alabama Medicaid Agency fiscal agent.

Ala. Admin. Code r. 560-X-6-.12

Rule effective October 1, 1982. Amended effective June 5, 1983; May 9, 1984; May 8, 1985; March 12, 1987. 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.