Ala. Admin. Code r. 560-X-7-.02

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

Section 560-X-7-.02 - Participation

(1) Eligibility. In order to participate in the Title XIX Medicaid program and to receive Medicaid payment for inpatient and outpatient hospital services, a hospital provider must meet the following requirements:

(a) Be certified for participation in the Title XVIII Medicare and Title XIX Medicaid programs as a short term or children's hospital. Hospital types are identified on the Hospital Request for Certification in the Medicare/Medicaid Program (HCFA-1514) or its successor.

(b) Be licensed as a hospital by the State of Alabama in accordance with current rules contained in the Alabama Administrative Code Chapter 420-5-7.

(c) Be in compliance with Title VI of the Civil Rights Act of 1964 and with Section 504 of the Rehabilitation Act of 1973.

(d) Submit a letter requesting enrollment.

(e) Submit a budget of cost for medical inpatient services for its initial cost reporting period, if a new facility.

(f) Execute the Alabama Medicaid Provider Agreement for participation in the Medicaid program.

(g) Submit a written description of an acceptable utilization review plan currently in effect.

(2) Enrollment. Hospitals should refer to the Alabama Medicaid Provider Manual (Becoming a Medicaid Provider - Chapter 2) for complete enrollment instructions.

(a) The effective date of enrollment cannot be earlier than the date of the Medicare certification.

(3) Participating out-of-state (border) hospitals are subject to all program regulations and procedures that apply to participating Alabama hospitals and shall submit copies of their annual certification from CMS, State licensing authority, and other changes regarding certification. "Border" is defined as within 30 miles of the Alabama state line.

(4) Nonparticipating hospitals are those hospitals which have not executed an agreement with Alabama Medicaid covering their program participation, but provide medically necessary covered out-of-state services.

(a) All Medicaid admissions to participating and nonparticipating facilities are subject to program benefits and limitations based on current Medicaid eligibility.

(b) Out-of-state prior authorization is required for organ transplants and select surgical procedures. (Refer to Rule No. 560-X-1-.27 and Rule No. 560-X-6-.13 respectively.

(5) The Fiscal Agent will be responsible for enrolling any Title XVIII (Medicare) certified hospital that wishes to enroll as a Qualified Medicare Beneficiary (QMB-only) provider.

Ala. Admin. Code r. 560-X-7-.02

Rule effective October 1, 1982. Amended effective November 10, 1983; November 11, 1985; December 10, 1986; February 9, 1988; July 13, 1989; October 13, 1992. Amended: Filed March 7, 1997; effective April 11, 1997.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 10, July 31, 2018, eff. 8/26/2018.

Author: Solomon Williams, Associate Director, Institutional Services

Statutory Authority: State Plan, §§2.7, 4.11, 4.13, Attachment 7.2A; Title XIX Social Security Act; 42 C.F.R. §§ 405.191, 431.51, 431.52, 431.107, 440.10, 440.20; Medicare Catastrophic Coverage Act of 1988 ( Public Law 100-360).