Current through Register Vol. 43, No. 02, November 27, 2024
(1)
The term "physician" shall mean
(a) a doctor
of medicine or osteopathy legally authorized to practice medicine and surgery
by the state in which the doctor performs such functions;
(b) a doctor of dentistry or of dental or
oral surgery who is licensed to practice in the state in which the service is
rendered, and legally authorized to perform such function but only with respect
to: surgery related to the jaw, the reduction of any fracture related to the
jaw or facial bones, or surgery within the oral cavity for removal of lesions
or the correction of congenital defects.
(2) Participation. Providers who meet
enrollment requirements are eligible to participate in the Alabama Medicaid
Program. An enrollment application may be requested from the Alabama Medicaid
Agency fiscal agent, or downloaded from the Medicaid website at
www.medicaid.alabama.gov.
Completed enrollment applications should be returned to the Alabama Medicaid
Agency fiscal agent.
Physicians having limited licenses will not be enrolled by the
Medicaid fiscal agent unless complete information as to the limitations and
reasons is submitted in writing to the Provider Enrollment Unit for review and
consideration for enrollment.
(3) Non-physician Practitioner
Services--Medicaid payment may be made for the professional services of the
following physician-employed practitioners:
physician assistants (PAs)
certified registered nurse practitioners (CRNPs)
PAs and CRNPs: The Alabama Medicaid Agency will make payment
for services of certified physician assistants (PAs) and certified registered
nurse practitioners (CRNPs) who are legally authorized to furnish services and
who render the services under the supervision of an employing physician with
payment made to the employing physician. Medicaid will not make payment to the
PA or CRNP.
(a) The
employing-physician must be an Alabama Medicaid provider in active
status.
(b) The PA or CRNP must
enroll with the Alabama Medicaid Agency and receive an Alabama Medicaid
provider number with the employing-physician as the payee.
(c) Covered services furnished by the PA or
CRNP must be billed under the PA's or CRNP's name and National Provider
Identifier (NPI) number.
(d) PA or
CRNP approved services include all injectable drugs, all laboratory services in
which the laboratory is CLIA certified to perform, and select CPT codes
authorized for independent CRNPs and are listed in Appendices H and O of the
Alabama Medicaid Billing Manual.
(e) The office visits performed by the PA or
CRNP will count against the recipient's yearly benefit limitation.
(f) The PA or CRNP must send a copy of the
prescriptive authority granted by the licensing board for prescriptions to be
filled. This information must be sent to the Alabama Medicaid Agency fiscal
agent.
(g) The PA or CRNP cannot
make physician-required visits to hospitals or other institutional settings to
qualify for payment to the physician or to satisfy current regulations as
physician visits.
(h) The PAs or
CRNPs cannot sign or place the initial prescription or order for home health
services or certain medical supplies, equipment, and appliances. Only the
physician who develops the recipient's written plan of care (the "ordering
physician") may sign and place the initial prescription or order for home
health services and certain medical supplies, equipment, and
appliances.
(i) The PA or CRNP may
both conduct and document the clinical findings from the required face-to-face
visit so that the ordering physician can place and sign the initial
prescription or order for certain medical supplies, equipment, and
appliances.
(j) The PA or CRNP may
conduct the required face-to-face visit so that the ordering physician can
place and sign the initial prescription or order for home health services.
However, the PA or CRNP may not document the clinical findings from the
required face-to-face visit in the recipient's medical record. If the PA or
CRNP conducts the required face-to-face visit, the PA or CRNP must communicate
the clinical findings to the ordering physician so that the ordering physician
can document those clinical findings in the recipient's medical
record.
(k) The employing-physician
need not be physically present with the PA or CRNP when the services are being
furnished to the recipient; however, he/she must be immediately available to
the PA or CRNP for direct communication by radio, telephone, or
telecommunication.
(l) The PA's or
CRNP's employing physician is responsible for the PA's or CRNP's professional
activities and for assuring that the services provided are medically necessary
and appropriate for the patient.
(m) There shall be no independent,
unsupervised practice by PAs or CRNPs.
(4) Physicians are expected to render
medically necessary services to Medicaid patients in the same manner and under
the same standards as for their private patients, and bill the Alabama Medicaid
Agency their usual and customary fee.
(5) Payments from Medicaid funds can be made
only to physicians who provide the services; therefore, no reimbursement can be
made to patients who may personally pay for the service rendered.
(6) Refer to Chapter 20 concerning
third-party insurance carriers.
(7)
The physician agrees when billing Medicaid for a service that the physician
will accept as payment in full, the amount paid by Medicaid for that service,
plus any cost-sharing amount to be paid by the recipient, and that no
additional charge will be made. The physician shall not charge or bill the
recipient for cancelled or missed appointments. Conditional collections from
patients, made before Medicaid pays, which are to be refunded after Medicaid
pays, are not permissible. The physician may bill the patient, in addition to
the cost-sharing fee, for services rendered in the following circumstances:
(a) When benefits are exhausted for the
year,
(b) When the service is a
Medicaid non-covered benefit.
(8) A hospital-based physician who is a
physician employed by and paid by a hospital may not bill Medicaid for services
performed therein and for which the hospital is reimbursed. A hospital-based
physician shall bill the Medicaid Program on a CMS-1500, Health Insurance Claim
Form or assign their billing rights to the hospital, which shall bill the
Medicaid Program on a CMS-1500 form. A hospital-based physician who is not a
physician employed by and paid by a hospital shall bill Medicaid using a
CMS-1500 Health Insurance Claim Form.
(9) A physician enrolled in and providing
services through a residency training program shall not bill Medicaid for
services performed. Medicaid will no longer require physicians enrolled in and
providing services through a residency training program be
assigned a pseudo Medicaid license number to be used on prescriptions written
for Medicaid recipients. Effective for claims submitted on or after January 1,
2012, interns and non-licensed residents must use the NPI or license number of
the teaching, admitting, or supervising physician.
(10) Supervising physicians may bill for
services rendered to Medicaid recipients by residents enrolled in and providing
services through a residency training program. The following rules shall apply
to physicians supervising residents:
(a) The
supervising physician shall sign and date the admission history and physical
and progress notes written by the resident.
(b) The supervising physician shall review
all treatment plans and medication orders written by the resident.
(c) The supervising physician shall be
available by phone or pager.
(d)
The supervising physician shall designate another physician to supervise the
resident in his/her absence.
(e)
The supervising physician shall not delegate a task to the resident when
regulations specify that the physician perform it personally or when such
delegation is prohibited by state law or the facility's policy.
(11) Off Site Mobile Physician's
Services shall comply with all Medicaid rules and regulations as set forth in
the State Plan, Alabama Medicaid Administrative Code, and Code of Federal
Regulations including but not limited to the following requirements:
(a) Shall provide ongoing, follow-up, and
treatment and/or care for identified conditions,
(b) Shall provide ongoing access to care and
services through the maintenance of a geographically accessible office with
regular operating business hours within the practicing county or within 15
miles of the county in which the service was rendered,
(c) Shall provide continuity and coordination
of care for Medicaid recipients through reporting and communication with the
Primary Medical Provider,
(d) Shall
maintain a collaborative effort between the off-site mobile physician and local
physicians and community resources. A matrix of responsibility shall be
developed between the parties and available upon enrollment as an off-site
mobile physician,
(e) Shall provide
for attainable provider and recipient medical record retrieval,
(f) Shall maintain written agreements for
referrals, coordinate needed services, obtain prior authorizations and
necessary written referrals for services prescribed. All medical conditions
identified shall be referred and coordinated, for example:
2. Comprehensive Audiological
services,
3. Comprehensive
Ophthalamological services,
4.
Appropriate referrals,
(g) Shall not bill Medicaid for services
which are free to anyone. Provider shall utilize a Medicaid approved sliding
fee scale based on Federal Poverty Guidelines,
(h) Shall ensure that medical record
documentation supports the billing of Medicaid services, and
(i) Shall obtain signed and informed consent
prior to treatment.
(12)
(a) Effective April 1, 2008, all
prescriptions for outpatient drugs for Medicaid recipients which are executed
in written (and non-electronic) form must be executed on tamper-resistant
prescription pads. The term "written prescription" does not include
e-prescriptions transmitted to the pharmacy, prescriptions faxed to the
pharmacy, or prescriptions communicated to the pharmacy by telephone by a
prescriber. This requirement does not apply to refills of written prescriptions
which were executed before April 1, 2008. It also does not apply to drugs
provided in nursing facilities, intermediate care facilities for the
intellectually disabled, and other institutional and clinical settings to the
extent the drugs are reimbursed as part of a per diem amount, or where the
order for a drug is written into the medical record and the order is given
directly to the pharmacy by the facility medical staff.
(b) To be considered tamper-resistant on or
after April 1, 2008, a prescription pad must contain at least one of the
following three characteristics:
1. one or
more industry-recognized features designed to prevent unauthorized copying of a
completed or blank prescription form; or
2. one or more industry-recognized features
designed to prevent the erasure or modification of information written on the
prescription by the prescriber; or
3. one or more industry-recognized features
designed to prevent the use of counterfeit prescription forms.
(c) To be considered
tamper-resistant on or after October 1, 2008, a prescription pad must contain
all of the foregoing three characteristics.
(13) Requirements for Placing the Initial
Written Prescription or Order for Home Health Services and Certain Medical
Supplies, Equipment, and Appliances.
(a) The
physician who develops the recipient's written plan of care ("the ordering
physician") is required to sign and place the initial prescription or order for
home health services and certain medical supplies, equipment, and appliances.
The ordering physician may only place the initial written prescription or order
after the required face-to-face visit is conducted and documented by an
authorized practitioner. Subsequent written prescriptions or orders for
refills, ancillary supplies, repairs or services, or re-certifications do not
require the ordering physician's signature or an additional face-to-face
visit.
(b) Requirements for Placing
the Initial Written Prescription or Order for Home Health Services.
1. Either the ordering physician or one of
the following authorized non-physician practitioners (NPP) may conduct the
required face-to-face visit so that the ordering physician can place and sign
the initial written prescription or order for home health services:
(i) Certified registered nurse practitioners
(CRNP) or clinical nurse specialists (CNS) working under a collaboration
agreement under Alabama law with the ordering physician;
(ii) Certified nurse midwifes under
applicable Alabama law;
(iii)
Physician assistants (PA) under the supervision of the ordering physician;
or
(iv) Attending acute or
post-acute physicians, if recipients are admitted to home health services
immediately after discharge from an acute or postacute stay.
2. Only the ordering physician may
document the clinical findings of the required face-to-face visit for the
initial written prescription or order for home health services in the
recipient's medical record. If an NPP conducts the required face-to-face visit,
the NPP must then communicate the clinical findings to the ordering physician
so that the ordering physician can document those clinical findings in the
recipient's medical record.
3. The
required face-to-face visit for the initial written prescription or order for
home health services must be related to the primary reason why the recipients
require the home health services and must be conducted within 90 days before or
30 days after the start of the services. The required face-to-face visit may be
conducted using telehealth systems.
4. The ordering physician is also required to
review the recipient's written plan of care every sixty (60) days to determine
the recipient's continued need for home health services.
(c) Requirements for Placing the Initial
Written Prescription or Order for Certain Medical Supplies, Equipment, and
Appliances.
1. Either the ordering physician
or one of the following authorized non-physician practitioners (NPP) may both
conduct and document the clinical findings from the required face-to-face visit
so that the ordering physician can place and sign the initial written
prescription or order for certain medical supplies, equipment, and appliances:
(i) Certified registered nurse practitioners
(CRNP) or clinical nurse specialists (CNS) working under a collaboration
agreement under Alabama law with the ordering physician;
(ii) Physician assistants (PA) under the
supervision of the ordering physician; or
(iii) Attending acute or post-acute
physicians, if recipients are admitted to home health services immediately
after discharge from an acute or postacute stay.
2. The required face-to-face visit for the
initial written prescription or order for certain medical supplies, equipment,
and appliances must be related to the primary reason why the recipients require
the certain medical supplies, equipment, and appliances and must occur no more
than 6 months prior to the start of services. The required face-to-face visit
may be conducted using telehealth systems.
3. The ordering physician is also required to
review the recipient's written plan of care annually to determine the
recipient's continued need for all medical supplies, equipment, and
appliances.
4. Not all initial
written prescriptions or orders for medical supplies, equipment, and appliances
require a face-to-face visit be conducted. The face-to-face visit requirement
is limited only to the certain medical supplies, equipment, and appliances that
are also subject to a face-to-face requirement under the Medicare DME program
as "Specific Covered Items" in
42 C.F.R.
410.38(g).
Author: Michael Williams, Associate Director,
Dental, EPSDT, and Physician Unit
Statutory Authority:
Code of Ala.
1975, §
34-24-75(d);
Title XIX, Social Security Act;
42 C.F.R. §§
447.15,
405.522, .523, 401, et
seq.; State Plan.
