Ala. Admin. Code r. 560-X-7-.04

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

Section 560-X-7-.04 - Bed And Board In Semi-Private Accommodations

(1) Medicaid will pay for semiprivate accommodations (two, three, or fourbed accommodations). When accommodations other than semiprivate are furnished, the following rules will govern:

(a) Private rooms medically necessary Payment may be made for private room or other accommodations more expensive than semiprivate only when such accommodations are medically necessary. Private rooms will be considered medically necessary when the patient's condition requires him to be isolated for his own health or that of others. The term isolation may apply when treating a number of physical or mental conditions. These include communicable diseases which require isolations of the patient for certain periods. Privacy may also be necessary for patients whose symptoms or treatments are likely to alarm or disturb others in the same room. Payment will be made for the use of intensive care facilities where medically necessary. In order for the private room to be covered by Medicaid, the following conditions must be met:

(1) The physician must certify at the time of admission or within 48 hours of the onset of the need for a private room, the specific medical condition requiring a private room.

(2) Such certification must appear in the hospital records as a written order by the physician.

(3) At the time the physician certifies the need for continued hospitalization, the private room must also be recertified as being medically necessary. Medicaid will not cover a private room on the basis of a retroactive statement of medical necessity by the physician. At the time the medical Medicaid Chapter 560-X-7 necessity for a private room ceases, the patient should be placed in the type accommodation covered by Medicaid.

(2) Private rooms not medically necessary When accommodations more expensive than semiprivate are furnished the patient because at the time of admission less expensive accommodations are not available or because the hospital has only private accommodations, Medicaid may pay for the semiprivate accommodations. THE PATIENT IS NOT TO BE BILLED OR REQUIRED TO PAY THE DIFFERENCE. When accommodations more expensive than semiprivate are furnished the patient at his request, the hospital may charge the patient no more than the difference between the customary charge for the most prevalent semiprivate accommodations and the more expensive accommodations at the time of admission. The hospital must require the patient to sign a form requesting the more expensive accommodation and agreeing to pay the difference. This form must be on file for review if questions arise regarding payment of private room charges.

(3) Customary charges mean amounts which the hospital is uniformly charging patients currently for specific services and accommodations. The most prevalent rate for semiprivate accommodations is the rate which applies to the greatest number of semiprivate beds.

Author:

Ala. Admin. Code r. 560-X-7-.04

Rule effective October 1, 1982. Amended: Filed March 7, 1997.

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