Current through Register Vol. 43, No. 02, November 27, 2024
The following methods shall be used in administering the
Medical Assistance Program to ensure that medical remedial care, and service
provided are of high quality, properly utilized and based on acceptable
professional medical standards, state and federal laws and regulations.
(1) Peer Review Committees, as appropriate,
will be established in Alabama for the purpose of settling disputes related to
charges made for professional and other medical assistance services. Problems
submitted to Peer Review Committees may originate with Alabama Medicaid Agency,
its fiscal agent, providers, and recipients. Additional Peer Review Committees
may be established as needed.
(a) Problem
referral procedure.
1. The fiscal agent shall
gather information about a problem discovered through claims processing and
attempt to resolve it with a provider or recipient.
2. Where a solution cannot be reached, the
facts will be submitted to the Alabama Medicaid Agency for
resolution.
3. Problems not
resolved by the Alabama Medicaid Agency may be referred to the appropriate Peer
Review Committee. Medicaid will assemble the facts and arrange for the Peer
Review Committee to consider the problems at a mutually agreeable time and
place. When a professional specialty consultation is needed, Medicaid may
arrange for the service.
(b) Facts about Peer Review Committees.
1. Peer Review Committees act independently
of fiscal agent and representatives of the Alabama Medicaid Agency.
2. No member of a Peer Review Committee who
has an ownership interest in a facility under review will participate in
committee action for the facility.
3. A member of a Peer Review Committee shall
not review a case on which he or a partner or associate is the attending
physician or dentist or in which he has had a professional
responsibility.
4. Peer Review
Committees may be provided with advice and consultation from other medical and
paramedical specialty agencies organized to deal with problems within their
specialty.
5. A majority of the
members of the committee will constitute a quorum.
6. Peer Review Committees will send their
reports to the Deputy Commissioner Program Administration, Alabama Medicaid
Agency. Information and reports are releasable on a need-to-know
basis.
7. A decision made by a Peer
Review Committee is final and binding on all parties if approved by the
Director, Programs, Alabama Medicaid Agency.
(c) Pharmacy Peer Review Committees. See
Chapter 16: Pharmacy Services: Rule
560-X-16-.23, Rule
560-X-16-.24, and Rule
560-X-16-.25.
(d) Optometric Peer Review Committee.
1. An Optometric Peer Review Committee will
be maintained in the state by Medicaid.
2. The committee shall meet at least twice
each calendar year to discuss problems and complaints relative to optometric
services within the Alabama Medicaid Program.
3. The committee shall function as an appeal
body on the request of Medicaid, optometric providers, and Medicaid
recipients.
4. Prior authorization
requests from optometrists denied by Medicaid shall be submitted for
consultation to the peer review committee before a final determination is
made.
(2)
Utilization Review. Each agency, organization, or institution providing care or
services in the Medicaid program, must have a utilization review plan approved
by Medicaid or its designated agent.
(a)
Medicaid or its designee will monitor facility utilization review activities on
inpatient hospital and extended care services.
(b) Utilization review for dental services is
a part of the dental professional review program.
(c) Medicaid monitors utilization review
activities concerned with evaluation and supervision of nursing and other
services provided by home health agencies.
(d) Utilization review for Pharmaceutical
services is a part of the pharmacy professional review program and monitored by
the Drug Utilization Review Program in cooperation with the fiscal agent. Other
monitoring activities are carried out by Medicaid in cooperation with the
fiscal agent.
(e) Medical review
for hospitals will be the responsibility of Medicaid or its designee.
(f) Medical review for skilled and
intermediate care nursing facilities, to include ICF/MR and ICF/MD, is the
responsibility of the Alabama Medicaid Agency.
(3) Medical Care Advisory Committee.
(a) The State Plan established the
requirement for a State Medical Care Advisory Committee to participate with the
Commissioner in policy development and program administration, including the
seeking of recipient participation in the Alabama Medicaid Program.
(b) The Commissioner shall arrange for
committee representation from licensed physicians and others from the health
and medical care professions familiar with the medical needs of low income
population groups. Representatives of consumer groups and an Indian Tribal
Member designee shall be included on the committee.
(c) The State Health Officer and the
Commissioner, Department of Pensions and Security shall be permanent ex officio
members of the committee.
(d) The
Medical Care Advisory Committee shall meet semiannually and at other times as
required to advise the Commissioner on medical assistance matters brought
before it.
(4) Quality
Assurance Committee:
(a) Medicaid may convene
standing Quality Assurance Committees to provide guidance, insight and
technical assistance as appropriate. The Committees will be convened and
members will be selected as appropriate for the initiative or program the
Agency is requesting guidance for.
(b) The Commissioner shall arrange for
committee representation from licensed physicians and other appropriate
providers who are familiar with the medical needs of low income population
groups that will be incorporated in the initiative or program.
Author: Drew Nelson, Director, Quality
Assurance
Statutory Authority: State Plan; 42 C.F.R.
§§ 401, et
seq.