Ala. Admin. Code r. 560-X-6-.01

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

Section 560-X-6-.01 - Physician Program-General

(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:

1. Eyeglasses,

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).

Ala. Admin. Code r. 560-X-6-.01

Rule effective October 1, 1982. Amended: effective April 15, 1983; March 12, 1984; May 9, 1984; June 9, 1985; March 12, 1987. Amended: Filed February 7, 1994; effective March 15, 1994. Amended: Filed December 7, 1994; January 12, 1995. Amended: Filed February 6, 1998; effective March 13, 1998. Amended: Filed May 8, 2000; effective June 12, 2000. Amended: Filed February 5, 2001; effective March 12, 2001. Amended: Filed May 10, 2002; effective June 14, 2002. Amended: Filed April 11, 2003; effective May 16, 2003. Amended: Filed February 10, 2005; effective March 17, 2005. Amended: Filed August 10, 2006; effective September 14, 2006. Amended: Filed June 11, 2008; effective July 16, 2008. Amended: Filed May 11, 2012; effective June 15, 2012.

Amended by Alabama Administrative Monthly Volume XXXIV, Issue No. 04, January 29, 2016, eff. 2/25/2016.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 11, August 31, 2018, eff. 9/24/2018.

Amended by Alabama Administrative Monthly Volume XXXVIII, Issue No. 03, December 31, 2019, eff. 2/14/2020.

Amended by Alabama Administrative Monthly Volume XLII, Issue No. 04, January 31, 2024, eff. 3/16/2024.

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.