Ala. Admin. Code r. 560-X-36-.06

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

Section 560-X-36-.06 - Application Process

(1) The case manager will receive referrals from hospital, nursing homes, physicians, the community and others for persons who may be eligible for home- and community-based services. For institutional residents residing in a facility for at least 90 days who are interested in transitioning into the community, the case manager should review referrals and intake information. This process will take place during the 180 consecutive day transition period.

(2) An initial assessment will be completed by the case manager in conjunction with the applicant's physician. This document will reflect detailed information regarding social background, living conditions, and medical problems of the applicant. A redetermination assessment must be completed annually to determine eligibility.

(3) The case manager, in conjunction with the applicant's physician and the client and/or caregiver will develop a plan of care. All services will be furnished pursuant to a written plan of care. Payment will not be made for waiver services furnished prior to the development of the plan of care. The plan of care will include objectives, services, provider of services, and frequency of services. Changes to the original plan of care are to be made as needed to adequately care for an individual. Revisions to the plan of care and the reasons for changes must be documented in the client's case record. Services provided must be documented on the client's care plan which is subject to the review of the Alabama Medicaid Agency. The plan of care must be reviewed by the case manager as often as necessary and administered in coordination with the recipient's physician.

(4) The Alabama Medicaid Agency has delegated the medical level of care determination to qualified trained individuals at the Operating agency.

(5) Medicaid requires the providers to submit an application in order to document dates of service provisions to long term care recipients.

(a) The long term care admission notification file maintains these dates of service.

(b) The applications will be automatically approved through systematic programming.

(c) The Alabama Medicaid Agency will perform random audits on a percentage of records to ensure that documentation supports the medical level of care criteria, physician certification, as well as other state and federal requirements.

(6) The Alabama Department of Senior Services (ADSS) is responsible for the assessment, evaluation of admissions, readmissions, and annual redeterminations for eligible participants receiving home and community-based services in accordance with the provisions of the Elderly and Disabled Waiver.

(7) The Alabama Medicaid Agency will provide to ADSS the approved Level of Care criteria and policies and procedures governing the level of care determination process.

(8) ADSS will designate a qualified medical professional to approve the level of care and develop the Plan of Care.

(9) Admissions, readmissions and annual redeterminations must be certified by a physician licensed to practice in Alabama.

(10) ADSS may utilize Medicaid staff for consultation on questionable admissions and annual redeterminations prior to a final decision being rendered.

(11) The Alabama Medicaid Agency will conduct a retrospective review on a monthly basis of a random sample of individuals served under the Elderly and Disabled Waiver to determine appropriate admissions and annual redeterminations. This review includes whether appropriate documentation is present and maintained and whether all state and federal medical necessity and eligibility requirements for the program are met.

(12) The Alabama Medicaid Agency will initiate recoupment of payment for services when it determines that state and federal, medical necessity, and eligibility requirements are not met.

(13) The Alabama Medicaid Agency may seek recoupment from ADSS for other services reimbursed by Medicaid for those individuals whom Medicaid determines would not have been eligible for Elderly and Disabled Waiver services or Medicaid eligibility but for the certification of waiver eligibility by ADSS.

Ala. Admin. Code r. 560-X-36-.06

Emergency rule effective March 18, 1985. Permanent rule effective July 13, 1985. Amended: effective November 18, 1987, June 6, 1990. Amended: Filed August 7, 1995; effective September 12, 1995. Amended: Filed July 14, 1999; effective August 18, 1999. Amended: Filed June 11, 2003; effective July 16, 2003. Amended: Filed July 17, 2003; effective August 21, 2003. Amended: Filed April 11, 2008; effective May 16, 2008. Amended: Filed September 11, 2008; effective October 16, 2008. Amended: Filed June 12, 2012; effective July 17, 2012.

Author: Monica Abron, Associate Director, LTC Program Management Unit

Statutory Authority:42 CFR Part 441, Subpart G; The Home-and Community-Based Waiver for the Elderly and Disabled.