Ala. Admin. Code r. 560-X-1-.13

Current through Register Vol. 42, No. 10, July 31, 2024

Section 560-X-1-.13 - Medicaid Payments And Recoupments For Health Services, Supplies, And Equipment

(1) Direct payments are made for allowable charges to providers for covered medical services and supplies furnished eligible Medicaid recipients.

Providers who wish to participate in the Alabama Medicaid Program must be enrolled, receive a provider number, and sign a contract with Medicaid.

(2) Crossover payments are partial payments to providers by Medicaid for covered Medicaid services, supplies and equipment furnished to recipients eligible for both Medicare and Medicaid.

(a) For Medicare covered services, providers of services, supplies, and equipment to eligible Medicare/Medicaid recipients must submit their claims primary to Medicare and not to the Medicaid fiscal agent.

(b) Claims paid by the Medicare contracted intermediary will be electronically forwarded to the Medicaid fiscal agent for payment to the provider of the deductible and coinsurance charges. This is the "crossover" payment and will be listed on the provider's Medicaid Remittance Advice (RA). Claims denied by the Medicare intermediary are not forwarded to the Medicaid fiscal agent.

(3) By entering into a contract with Medicaid, the provider acknowledges that payments thereunder are subject to review, audit, adjustment and recoupment actions. In the event of any transfer, sale, assignment, merger or replacement between and among providers, Medicaid may look both to the original provider and any successor, transferee or replacement provider for recovery of any funds improperly paid. Providers should take this right of Medicaid into account and make appropriate provision therefor in their business transactions.

(4) All sites providing laboratory testing services to Medicaid recipients, either directly by provider, or through contract, must be Clinical Laboratory Improvement Amendments (CLIA) certified to provide the level of testing complexity required. Providers are responsible to assure Medicaid that all CLIA regulations are strictly adhered to, both now and as regulations change in the future. Providers are responsible for providing Medicaid waiver or certification numbers as applicable.

(5) Laboratories which do not meet CLIA certification standards are not eligible for reimbursement for laboratory services from the Alabama Medicaid Program.

Ala. Admin. Code r. 560-X-1-.13

Rule effective October 1, 1982. Amended: Effective January 14, 1987. Effective May 11, 1993. Amended: Filed September 11, 2013; effective October 16, 2013.

Author: Kathy Hall, Deputy Commissioner, Program Administration

Statutory Authority: Social Security Act, Title XIX, §1902(a)(32); 42 C.F.R. § 447.10; Clinical Laboratory Improvement Amendments of 1988 (CLIA); P. L. 100-578 (42 U.S.C. Section 263a); and State Plan, Attachment 3.2-A.