Ala. Admin. Code r. 560-X-6-.09

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

Section 560-X-6-.09 - Consent Forms Required Before Payments Can Be Made

(1) Abortions: A claim seeking payment for an abortion must be accompanied by one or more (depending on the circumstance) of the forms required by federal law and a copy of the medical records. Payment is available for abortions as provided under federal law.

(a) In the event the abortion does not meet the requirements of federal law, and the recipient elects to have the abortion, the provider may bill the recipient for the abortion.

(2) Sterilization: A claim seeking payment for sterilization must be accompanied by a sterilization form (Form 193) or Medicaid approved substitute.

(a) Sterilization by Hysterectomy. Payment is not available for a hysterectomy if:

1. It was performed solely for the purpose of rendering an individual permanently incapable of reproducing, or

2. If there was more than one purpose to the procedure, it would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing.

(i) Hysterectomy procedures performed for the sole purpose of rendering an individual incapable of reproducing are no longer covered under Medicaid. Hysterectomies done as a medical necessity as treatment of disease can be paid for by the Medicaid funds under the physician's program.

(b) A claim seeking payment for a hysterectomy performed for reasons of medical necessity, and not for purpose of sterilization, must be accompanied by a Hysterectomy Consent Form PHY-81243 (rev. 02-10-2010) or Medicaid approved substitute. The doctor's explanation to the patient that the operation will make her sterile, and the doctor's and recipient's signature must precede the operation except in the case of unusual circumstances.

1. The physician who performed the hysterectomy must complete Part IV. Unusual Circumstances of the revised hysterectomy consent form certifying that, (1) the patient was already sterile when the hysterectomy was performed; the cause of sterility must be stated and supporting medical records (history and physical, operative notes, and discharged summary) must be attached, or (2) the hysterectomy was performed under a life-threatening emergency situation in which prior acknowledgement was not possible. Medical records supporting life-threatening emergency situation must be attached, or (3) the hysterectomy was performed during a period of retroactive Medicaid eligibility, and before the operation was performed, the physician informed the recipient that she would be permanently incapable of reproducing as a result of the operation.

2. Surgeons are responsible for submitting hard copy hysterectomy consent forms to the Alabama Medicaid Agency fiscal agent. The form must be signed by both the patient, or a representative, and the physician.

Ala. Admin. Code r. 560-X-6-.09

Rule effective October 1, 1982. Amended effective March 12, 1987. Emergency rule effective March 1, 198 9. Amended effective June 16, 1989. Amended: Filed February 7, 1994; effective March 15, 1994. Amended: Filed May 10, 2002; effective June 14, 2002. Amended: Filed April 11, 2003; effective May 16, 2003. 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.

Author: Beverly Churchwell; Program Manager; Medical Support

Statutory Authority: Title XIX, Social Security Act; 42 C.F.R. §§401, etseq.; State Plan.