Ala. Admin. Code r. 560-X-7-.15

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

Section 560-X-7-.15 - Inpatient Non-Covered Services

(1) Items and services for which there is no legal obligation to pay -- Free services are excluded from coverage, (e.g., chest x-rays provided without charge by health organizations).

(2) Items and Services which are required as a result of war -- Those required as a result or act of war, occurring after the effective date of the patient's current coverage are not covered.

(3) Personal comfort items, such as radio, television, telephones, beauty and barber services, which do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member are not covered.

(4) Routine physical check-ups required by third parties, such as insurance companies, business establishments or other government agencies are not covered.

(5) Braces, orthopedic shoes, corrective shoes, or other supportive devices for the feet are not covered.

(6) Custodial care or sitters are not covered.

(7) Cosmetic surgery or expenses in connection with such surgery are not covered. Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt repair of accidental injury or for the improvement of the function of a malformed body member. For example, this exclusion does not apply to surgery in connection with treatment of severe burns or repair of the face following a serious automobile accident, nor to surgery for therapeutic service, which coincidentally also serves some cosmetic purpose.

(8) Items and services to the extent that payment has been made, or can reasonably be expected to be made under a Workman's Compensation Law, or plan of the United States, or a state may not be paid for by Medicaid.

(9) Inpatient hospitalization for routine diagnostic evaluations that could be satisfactorily performed in the outpatient department of the hospital, or in a physician's office or appropriate clinic, is not covered.

(10) Psychological evaluations and testing and psychiatric evaluations are not covered by Medicaid except where actually performed by a physician in person.

(11) Speech therapy is not covered by Medicaid unless actually performed by a physician in person.

(12) Reserved Bed Charges -- There is no provision under the Alabama Medicaid Program for payment of reserved inpatient hospital beds for patients on a pass for a day or more.

(13) Inpatient services provided specifically for a procedure that requires prior approval is not covered unless prior authorization from Medicaid for the procedure has been obtained by the recipient's physician. In the event that the recipient is receiving other services which require inpatient care at the time the procedure is performed, any charges directly related to the procedure will be non-covered and subject to recoupment. Additionally, all admissions must meet the Adult and Pediatric Inpatient Care Criteria.

Ala. Admin. Code r. 560-X-7-.15

Rule effective October 1, 1982. Amended effective June 14, 1990. Amended: Filed March 7, 1997; effective April 11, 1997. Amended: Filed August 6, 1999; effective September 10, 1999. Amended: Filed May 12, 2010; effective June 16, 2010.

Author: Lynn Sharp, Associate Director, Policy Development Unit

Statutory Authority: State Plan, Attachment 3.1A, pp. 1, 1.1; Title XIX, Social Security Act; 42 C.F.R. §§405.310, 405.311, 405.314, 405.316.