State of alabama medicaid provider manual

Postpartum care includes office visits following vaginal or cesarean section delivery for routine postpartum care within sixty-two 62 days post delivery. Additional claims for routine visits during this time should not be filed. Delivery only: If the physician performs the delivery only, he must utilize the appropriate CPT-4 delivery only code vaginal delivery only or C-section delivery only.

Delivery fees include all professional services related to the hospitalization and delivery which are provided by the physician; therefore, additional claims for physician's services in the hospital such as hospital admission, may not be filed in addition to a claim for delivery only. Obstetrical ultrasounds are limited to two per pregnancy. Generally, first ultrasounds are conducted to detect gestational age, multiple pregnancies, and major malformations. Second ultrasounds may be conducted to detect fetal growth disorders intrauterine growth retardation, macrosomia and anomalies that would appear later or may have been unrecognizable in the earlier scan.

Additional ultrasounds may be prior approved by the Alabama Medicaid Agency if a patient's documented medical condition meets any of the following criteria:.

Echogenic bowel grades 2 and 3 are indicative of an increased risk of cystic fibrosis and Trisomy 21 ;. Maternity Waiver subcontractors should contact their Primary Provider for information regarding obstetrical ultrasounds.

Internal prosthetic devices i. The cost of the device is reimbursed through the payment of the inpatient hospital per diem rate and is not separately reimbursable.

Psychiatric evaluations shall be limited to one per calendar year, per provider, per recipient. Office visits shall not be covered when billed in conjunction with psychotherapy codes. Payment is made in accordance with the provider's reasonable charge profile allowance for an initial office visit for the appropriate level of service. Examples of medical necessity include prompt repair of accidental injuries or improvement of the functioning of a malformed body member.

When multiple or bilateral surgical procedures, which add significant time or complexity are performed at the same operative session, through the same incision or separate incisions in the same operative field, payment will be made for the procedure with the highest allowed amount and half of the allowed amount for each subsequent procedure.

This also applies to laser surgical procedures. Certain procedures are commonly carried out as integral parts of a total service and as such do not warrant a separate charge. When incidental procedures e. Laparotomy is covered when it is the only surgical procedure performed during the operative session or when performed with an unrelated or incidental surgical procedure. Physical therapy is covered only when prescribed by a physician and provided in a hospital setting.

Group Therapy is not covered when performed by a case worker, social services worker, mental health worker, or any counseling professional other than a physician. To be a covered benefit speech therapy must be prescribed by and performed by a physician in his office. Speech therapy performed in an inpatient or outpatient hospital setting, or in a nursing home is a covered benefit, but is considered covered as part of the reimbursement made to the facility and should not be billed by the physician.

Family therapy is not covered unless the patient is present. Family Therapy is included in the annual office visit limit. Family Therapy is not covered when performed by a case worker, social service worker, mental health worker, or any counseling professional other than a physician. Documentation in the medical record should contain all of the following:.

Must state "Work Incentive Program. Emergency rule effective January 22, Amended effective April 11, Emergency rule effective December 1, Emergency rule effective March 4, Emergency rule effective July 1, Amended effective October 12, Emergency rule effective January 1, Amended effective April 14, Amended: Filed December 9, ; effective January 14, Amended: Filed September 6, ; effective October 11, Amended: Filed March 12, ; effective April 16, Amended: Filed October 12, ; effective November 16, Visits counted under this quota will include, but not be limited to, visits for: prenatal care, postnatal care, family planning, second opinions, consultations, referrals, psychotherapy individual, family, or group , for ESRD services not covered by the monthly capitation payment, and care by ophthalmologists for eye disease.

Physician visits provided in a hospital outpatient setting that have been certified as an emergency do not count against the annual office visit limit.

In addition to the office visits referred to in paragraph 1 above, Medicaid covers up to 16 inpatient dates of service per physician, per recipient, per calendar year. For purposes of this limitation, each specialty within a group or partnership is considered a single provider.

Professional interpretation may not be billed in addition to hospital visits if the provider reviews results in the medical record or unofficially interprets medical, laboratory, or radiology tests. Review and interpretation of such tests and results are included in the evaluation and management of the inpatient. Medicaid will cover either one hospital visit or professional interpretation s up to the allowed benefit limit for most services. Refer to the Alabama Medicaid Provider Manual for additional guidelines.

Professional interpretations performed by physicians of other specialties for services in this procedure code range are included in the hospital visit reimbursement. Professional interpretations may be billed separately only by the specialist responsible for the official medical record report of interpretation. Only one professional interpretation per x-ray will be paid. Claims paid in error will be recouped. If both are billed, only the discharge shall be paid.

Amended effective March 12, ; July 10, ; January 12, ; December 12, Amended: Filed November 6, ; effective December 11, Amended: Filed July 14, ; effective August 18, Amended: Filed June 11, ; effective July 16, Amended effective July 8, ; July 9, ; March 12, Repealed effective July 10, Conditional collections to be refunded post payment by Medicaid and partial charges for balance of Medicaid allowed reimbursement are not permissible.

Billing recipient for services not paid by Medicaid due to provider correctable errors on claims submission or untimely filing is not permissible. Amended effective July 9, ; June 8, ; March 12, The copayment amount does not apply to services provided for the following:. History: Rule effective June 8, Amended effective July 9, ; March 12, Amended : Filed December 7, ; effective January 12, Residents or nurses who escort a patient may not bill either service.

The purpose of the following policy statements is to provide assistance to providers seeking to bill procedures for critical care. General guidelines are:. Both may not be billed. One EPSDT screen for the hospitalization will encompass all diagnoses identified during the hospital stay for referral purposes.

Ellie Hartman Speaker. Ellie Hartman, Ph. Chethan Bachireddy Speaker. He is a physician, researcher, and public servant dedicated to improving health for vulnerable populations. Prior to coming to Virginia, he was a National Clinician Scholar at the University of Pennsylvania where his work focused on two areas: 1 improving health for populations with high rates of HIV infection, substance use disorders, mental illness, and justice involvement and 2 applying insights from behavioral economics and clinical trial design to test strategies and technologies to help form healthy habits.

He is excited to learn and collaborate to improve the health and well-being of the individuals, families, and communities who call Virginia home.

Jeremy Vandehey Moderator. Jeremy Vandehey, J. Hospital Consolidation. Jaime King Speaker. Jaime S. King is the Bion M. Concentration on Law and Health Sciences. She is the Co-Founder and Executive Editor of The Source on Healthcare Price and Competition, a multi-disciplinary web-based resource about healthcare price and competition. Professor King has testified before Congressional committees on health insurance mergers and price transparency and currently sits on the Board of the American Society of Law, Medicine, and Ethics.

She holds a Ph. Carissa Dougherty Speaker. Carissa Dougherty, LCSW, has over 18 years experience providing direct clinical practice, program management, and policy work. Dougherty previously managed an array of permanent and transitional supportive housing programs for persons with mental health and substance use issues. She has co-chaired the local homeless Continuum of Care and provided Mental Health First Aid training to hundreds of homeless service and housing providers.

She leads a team of program specialists and policy analysts responsible for stakeholder engagement, system coordination, and policy initiatives. Prior to this role, she served as a Senior Advisor with a focus on coordinating services to address the housing needs for persons with IDD and behavioral health disabilities, exploring the sustainable financing options for health and housing initiatives, and promoting policies and programs that support such endeavors.

Improving Health through Housing. Starla Ledbetter Speaker. With over 30 years of healthcare experience, Ms. Vanessa Avery Speaker. She manages all aspects of affirmative enforcement by the office, including multi-district cases involving antitrust and government program fraud, consumer protection, the opioid epidemic, the Affordable Care Act, immigration, the environment, privacy and data security, as well as cases pending locally.

She handled a broad variety of cases on behalf of the United States, its agencies and employees. She also spent over a decade in law firm practice focusing on business and financial litigation. Terry Cothran Speaker.

His team provides support to the Oklahoma Health Care Authority state Medicaid agency in managing the pharmacy benefits for our state Medicaid members. Sue Kvendru Speaker. Jami Snyder Speaker. Jackie Prokop Speaker. Greg Moody Moderator. Brett DeLange Speaker. Bob Russell Moderator. Andy Mullins Speaker. Alice Lind Speaker. Craig Nale Speaker. Jackson, the President of the Maine Senate.

Craig practiced law at a firm in Portland, Maine, for two years prior to joining the Maine Legislature in Stacey Schubert Speaker. Stacey received her B. Shannon Bresaw Speaker. As Program Director, Ms. Through this initiative, Ms. Bresaw and her team work to empower employers to challenge stigma and provide supportive work environments for people in recovery and those impacted by substance use disorders. At Granite United Way, Ms. Bresaw oversees public health strategies and initiatives and works to align these efforts with existing collaborations, partnerships, and Community Health Improvement Plans.

In addition, Ms. Born and raised in NH, Ms. Bresaw received her Master of Social Work Degree in from the University of New Hampshire, with a concentration in community and administrative practice. She has worked in the field of public health and substance use disorders since In her current role, Ms. Bresaw provides ongoing technical assistance and support to key sectors to ensure the use of best practice approaches in public health and prevention.

Bresaw has significant experience in the development of strategic plans, logic models, evaluation plans, and work plans designed to impact crucial public health issues in our communities. Sarah Finne Speaker. Sarah Finne, DMD, MPH brings over 30 years of experience from both private practice dentistry and public health supervision of a large school-based dental program in New Hampshire to her work in Dental Medicaid.

Sarah Brummett Speaker. The Office is legislatively mandated as the state coordinating body for suicide prevention, intervention and postvention efforts. The Office sets statewide priorities and works with state agencies and community organizations to develop and implement effective strategies, including a community grant program, means restriction education initiatives, the Zero Suicide initiative, education and awareness programs, emergency department and hospital outreach and education, the Colorado-National Collaborative, federal grant-funded initiatives, Mental Health First Aid, and a school grant program.

Brummett practiced family and appellate law in both Colorado Springs and the Denver Metro area. Sabrina Corlette Speaker.

At CHIR she directs research on health insurance reform issues. Her areas of focus include state and federal regulation of private health insurance plans and markets and evolving insurance market rules. Prior to joining the Georgetown faculty, Ms.

From to , Ms. Corlette worked as a professional staff member of the U. After leaving the Hill, Ms. Corlette is a member of the D. Bar and received her J. She lives in Alexandria, Virginia with her husband and two daughters. How to Slice the Pie? Market Segmentation. Robin Wagner Speaker.

Richard N. He works to expand publicly funded health coverage; protect patient autonomy, especially in reproductive and end-of-life care; and support safety-net health care providers.

Richard Gottfried Speaker. Regan Foust Speaker. She also comes with prior experience replicating effective youth development interventions and evaluating and improving child welfare and educational programs. Paul Precht Speaker. Prior to starting at CMS in , Mr. Paige Duhamel Speaker. She began her work in the health insurance arena in law school with research on the impact of discriminatory health insurance benefit design on marginalized populations. In the four years that Ms.

Duhamel has been with OSI, her work has focused on regulatory and legislative policy development, including the Surprise Billing Protection Act, legislation to align New Mexico law with the Affordable Care Act, protections against unscrupulous purveyors of short term and limited benefits plans, and guarantees for network adequacy and prompt and transparent benefit utilization review. Nicole Gastala Speaker.

Her interests include treating whole families with a special focus on preventative health care, group visits, and medication-assisted treatment for opioid use disorder.

Michael White Speaker. Michael White has worked in the field of substance use disorder for over 9 years with an additional 3 years working with children and families. Michael specializes in substance use disorder program development between community agencies and judicial systems and has developed, implemented, and supported the integration of Medication Assisted Treatment into county and state correctional facilities located in Alaska, Arizona, Montana, North Dakota, Wisconsin, and Texas.

At Community Medical Services Michael supervises a team that closely works with Superior Court Drug Court Programs along with coordinating care to and from county and state correctional facilities. His experience also includes working within family courts, Department of Child Safety, and obtaining resources for pregnant women with substance use disorders by collaborating with community partners. Michael is a national presenter in the areas of Collective Impact as an effective tool for the continuum of care, pregnancy and opioid dependence, along with Opioid treatment within Criminal Justice systems.

Meredith Ray-LaBatt Speaker. For more than twenty years, Meredith has worked on behalf of children and their families, spending much of her career working to address the complex needs of children with mental health challenges who become involved with various other child-serving systems, including substance use, juvenile justice and child welfare. Megan worked on Capitol Hill for 13 years for both Rep. Matthew Statman Speaker.

Matt is a person in recovery from a substance use disorder who has spent his career helping those with substance use disorders initiate and sustain recovery. Mark Schulz Speaker. He brings together key individuals and groups that have the talents and resources needed to develop, foster, fund and implement new, integrated community services at the local level. Mark has served as an Ombudsman for Long-Term Care learning firsthand the complex reality our most vulnerable adults live with each day.

Before that role, he served with the US military in various leadership positions with responsibility for small and large-scale, multi-faceted teams and complex financial situations. Grant Foundation. She has published over papers, editorials, intervention training manuals, and several book chapters, focused on improving health care for diverse racial and ethnic populations.

In October , she was elected as a member of the National Academy of Medicine in acknowledgement of her scientific contributions to her field. Linette Scott Moderator. Leann Johnson Speaker. Leann is the director of the Equity and Inclusion Division for the Oregon Health Authority, joining the agency in Leann has 25 years of leadership experience developing equity, diversity and inclusion programs.

Kevin Martin Speaker. He has 13 years of healthcare experience ranging from systems management to program integrity and mostly focusing on data analysis in various forms. Recently he has been involved in several large payment reform efforts including, implementation of the Enhanced Ambulatory Patient Grouper methodology for outpatient hospitals and developing a per member per month payment model for FQHCs.

Ken DeCerchio Speaker. Prior to joining the staff of Children and Family Futures, Mr. Katie Gudiksen Speaker. Katherine L. Gudiksen, Ph. Her work focuses on policies to address rising healthcare costs with an emphasis on state-level interventions to promote competition. While at The Source, she developed the pharmaceutical page to track and analyze state legislation to address rising drug prices. She also holds an A. Kate McEvoy Speaker.

This has streamlined and simplified the program for both members and providers, freed up resources for an extensive array of care delivery and value-based payment interventions, and enabled the program to reduce both per member, per month costs and overall spend. Kate is a graduate of Oberlin College with a B.

Her background is in community-based services for older adults, and she is the author of Connecticut Elder Law, a treatise that is republished each year. Karynlee Harrington Speaker. Both State agencies are responsible for promoting the transparency of health care costs and quality in the State of Maine. MQF is responsible for improving health care quality in the state. Prior to her current role, Ms. She earned her B. Julia Wacloff Speaker. Julia works with ADHS leadership and management on a variety of public health functions as related to oral health and has been in her current position for ten years.

She was responsible for developing the first comprehensive state oral health plan for Arizona. She has over 20 years of experience in various public health settings providing needs assessment, policy development and quality assurance at local, state and national levels.

Johnnie Chip Allen Speaker. In this position Mr. Allen is responsible for developing agency-wide goals, objectives and strategies to eliminate health disparities and promote health equity for all Ohio residents. Additionally, Mr. Allen works in partnership with national public health organizations, state cabinet-level agencies and a variety of public health programs to target services to disenfranchised groups, measure program performance and assess outcomes.

Allen has served in various public health capacities. Allen has implemented statewide social marketing activities to respond to chronic diseases; developed enterprise-wide program evaluation systems; and pioneered the use of market research analytic tools with GIS mapping capability to respond to health inequities.

John-Pierre Cardenas Speaker. Cardenas has played a critical role in the shaping of important health coverage legislation in Maryland including the Maryland Easy Enrollment Health Insurance Program. Cardenas also manages agency relationships with state and federal legislators and regulatory industries; oversees the implementation and administration of the State Reinsurance Program; and provides end-to-end management and oversight of carrier relationships ranging from consumer enrollment to experience.

He has been with the Maryland Health Benefits Exchange since in a variety of roles before assuming his current position in Jodi Manz Speaker. As Assistant Secretary, Jodi supports the development of health and behavioral health policy in the Commonwealth.

Jason Rachel Speaker. Jason Rachel, Ph. In this role, he is responsible for providing executive leadership in the management and implementation of both current and new integrated care programs.

Rachel directs and oversees all operations, policies, contract compliance and quality monitoring activities within the division to provide high quality, person-centered coordinated care services. Jane Wishner Speaker. An attorney with extensive experience as a litigator, researcher and advocate, Ms. New Recipes to Control Rx Pricing. Jane Beyer Speaker. She served as legal counsel to the Washington State House of Representatives for twenty years, working on a broad range of health, behavioral health, long term care, human services and criminal justice issues.

James A. Clair Speaker. Jim provides executive consulting services to technology-enabled companies in the pharmacy services and SaaS space. Heidi Haley-Franklin Speaker. Heidi has over 20 years of experience working with individuals and families in private practice, group homes, long-term and home health care settings.

Thomas in St. Heather Sanborn Speaker. After serving one term as a Representative in the Maine House, Heather ran for the State Senate and is currently serving her first term, representing part of Portland and Westbrook, Maine. A former public school teacher and attorney, Heather now owns and runs Rising Tide Brewing Company with her husband, Nathan, in Portland.

Heather and her husband live in Portland with their teenage son. Heather Winfield-Smith Speaker. In her role as Section Supervisor, she coordinates the Hawaii Stop Flu at School Program, a school-located influenza vaccination program that conducts annual clinics in over participating schools, statewide. Hazel Alvarenga Speaker. Gary Cohen Speaker. Gary Cohen has been a pioneer in the environmental health movement for thirty years.

He was also instrumental in bringing together the NGOs and hospital systems that formed the Healthier Hospitals Initiative. All three were created to transform the health care sector to be environmentally sustainable and serve as anchor institutions to support environmental health in their communities. He has helped build coalitions and networks globally to address the environmental health impacts related to toxic chemical exposure and climate change.

Cohen is a member of the International Advisory Board of the Sambhavna Clinic in Bhopal, India, which has been working for over 25 years to heal people affected by the Bhopal gas tragedy and to fight for environmental cleanup in Bhopal. Erica Guimaraes Speaker. Erica Guimaraes is a program coordinator in the Office of Community Health Workers at the Massachusetts Department of Public Health, where she assists in promoting best practices for CHW integration into health care and public health teams.

Ellyson Stout Speaker. Stout directs the Suicide Prevention Resource Center SPRC project at EDC, leading a team that provides resources and capacity building services to state and local leaders, health and behavioral health agencies and organizations, federal suicide prevention grantees, and national stakeholders involved in suicide prevention efforts across the country.

She has worked in the suicide prevention field for 12 years, with a focus on building state and tribal suicide prevention workforce and infrastructure capacity for strategic, comprehensive, evidence-informed suicide prevention programs. Stout serves as a subject matter expert on substance abuse and suicide prevention collaboration, strategic planning, accessing and using surveillance data for program planning and evaluation, and knowledge translation and dissemination.

She has presented widely at national and local conferences, as well as participating in federal and other national advisory groups, including a current national effort to develop recommendations for state suicide prevention infrastructure. Stout holds a Masters of Science in Health Communication, and has worked with state and local audiences to build capacity in strategic and effective messaging and campaigns for behavior change. Doug Thomas Speaker.

Doug has worked in the mental health and substance use disorder field for over 24 years in various capacities as a direct service provider and administrator. He has worked in both urban and rural settings and previously oversaw County services implementing evidence-based service delivery models; expanding prevention, treatment and recovery support services in rural Utah including work with tribal government.

Doug is passionate about prevention and early intervention and integrating prevention efforts into systems to produce lasting outcomes to reduce risk and increase the well-being of individuals, families, and communities. Dawn Lambert Moderator. Within that role, her focus is on person-centered strategy and innovation. A Little More Help Please? Improving Assisted Living. David Huang Speaker. Chan School of Public Health.

David Crall Speaker. After voters legalized medical marijuana in Oklahoma through ballot initiative, David was the lead Senate staffer on the bicameral Medical Marijuana Working Group, which held public meetings with experts from the marijuana industry, state agencies, law enforcement, the medical field, the Oklahoma business community and NCSL throughout the summer of to study how best to implement the new medical marijuana program.

David drafted the resulting Oklahoma Medical Marijuana and Patient Protection Act, which created a regulatory framework for the program, as well as various other pieces of legislation relating to medical marijuana. David Cassetty Speaker. David serves as the Deputy Commissioner of Insurance in Las Vegas, and oversees the consumer services and enforcement sections of the Division.

David also has spent many years as an assistant attorney general, in Vermont and American Samoa, and started his law career in private practice in Florida, where he was board certified in appellate practice, mostly working on behalf of insurance companies. Dave Richard Speaker. As the programs undergo transformation to even better fit the needs of state and its residents, he is committed to the fundamental goal of improving the health and well-being of all residents.

Richard believes the right way to achieve success is to work closely with stakeholders in all aspects of Medicaid. Richard joined DHHS after leading The Arc of North Carolina, an advocacy and service organization for people with intellectual and developmental disabilities, as its Executive Director for 24 years.

Daphnne Brown Speaker. She provides support to families, advocates and service providers on family driven care, systems advocacy, and family empowerment. Daphnne provides training and technical assistance to family-run and provider agencies in preparation for the transformation to Medicaid Managed Care. Daphnne has a B. Daniel Tsai Speaker. In his role, Tsai is responsible for ensuring a robust and sustainable MassHealth program that best meets the needs of members. That includes developing new policies, payment models, and operational processes that improve the way health care is delivered to 1.

He has significant experience on the design and implementation of innovative, state-wide health care payment systems for Medicaid, Medicare, and Commercial populations, and has worked closely with multiple state Medicaid programs, private payers, and health services companies.

He received a Bachelor of Arts in applied mathematics and economics from Harvard University. Assistant Secretary Tsai lives with his wife and son in Cambridge.

Which Way is the Wind Blowing? MCOs at a Crossroads. Connor McDonnell Speaker. Prior to OHCS, he worked in a homeless shelter as a housing case manager, for elected officials, and in various levels of government working in different capacities at the nexus of health and housing.

Colleen Sonosky Moderator. Clinton Lasley Speaker. Born and raised in Alaska, Mr. Lasley has 25 years of business management and organizational leadership experience with a passion for elders and promoting public health. Catherine Kirk Robins Speaker. Kirk Robins has worked to develop, progress, and implement state-level policy to address prescription drug affordability, and continues to collaborate with other state initiatives to improve legislative approaches to this issue.

Betsey Tilson Speaker. In this role, she promotes public health and prevention activities, as well as provides guidance and oversight on a variety of cross-Departmental issues.

She has been active and has served in leadership roles in many local, state, and national pediatric, public health and preventive medicine organizations. Beth Waldman Speaker. Beth Waldman is a Senior Consultant at Bailit Health with national expertise in health care policy, program development and implementation, specializing in Medicaid and CHIP programs and coverage for the uninsured.

Prior to joining Bailit Health, Beth worked for 12 plus years within the Massachusetts Medicaid program and served as the Massachusetts Medicaid Director from — Beth Kuhn Speaker.

Beth Kuhn is Chief Engagement Officer at the Kentucky Cabinet of Health and Family Services, leading policy and operational efforts to better integrate workforce, health and human service programs. She was until recently Commissioner of the Kentucky Department of Workforce Investment, collaborating with many partners in a system of Kentucky Career Centers providing employment, vocational rehabilitation, veterans, and other workforce services to employer and individual customers.

Prior to her appointment as Commissioner in December of , Beth served as Sector Strategies Director, assisting with the design and implementation of industry sector-based approaches to workforce and economic development. Beth has over 30 years of experience creating and implementing innovative workforce programs. Ben Steffen Speaker. The Maryland Health Care Commission is an independent regulatory agency whose mission is to plan for health system needs, promote informed decision-making, increase accountability, and improve access to health care and health care coverage in Maryland.

This Center has analytic and operational responsibilities for health care practitioner initiatives in the state including development of an All Payer Data Base and the Patient Centered Medical Home Program. Steffen serves as a spokesperson for the Commission at state and national levels on state health care expenditures, physician work force, physician uncompensated care, and information security.

Before joining the MHCC, he served as a budget analyst in the Health, Housing, and Income Security Division of the Congressional Budget Office, among activities he worked on the modeling that produced the estimates of reforms that ultimately led to the Medicare Prospective Payment System. He is a former Peace Corps volunteer to Nepal. Amir Bassiri Speaker. As a California native, Amir earned his B. W from Columbia University.

Alfred Johnson Speaker. Alfred has served in various staff and management capacities in private industry, county and state government serving vulnerable populations since Alfred has worked for the Division of Quality Assurance since While in DQA, Alfred has been instrumental in establishing collaborative statewide working relationships with counties, care management organizations, advocates and industry representatives to help improve the quality of care in assisted-living settings.

Alex Blandford Speaker. Alana Knudson Speaker. Knudson has over 25 years of experience implementing and directing public health programs, leading health services and health policy research projects, and evaluating program effectiveness. Her research and policy project findings have informed state, Tribal, and Federal health policy. Ashley Billups Speaker. A lifelong Oklahoman, Ashley has dedicated herself to the people of Oklahoma. Ashley is active in her political party at the state level, recently served as the Speaker of the House of Oklahoma Intercollegiate Legislature, and volunteers with a nationally accredited animal rescue, Tornado Alley Bulldog Rescue.

When she is not saving dogs, Ashley enjoys fishing, reading, and cooking although not at the same time. EPSDT services include but are not limited to: comprehensive health and developmental history screenings, health education, laboratory tests, vision services, dental services, and hearing services. This may include a course of treatment that includes mere observation or no treatment at all; b. Is provided in accordance with generally accepted professional standards for health care in the United States; c.

Is clinically appropriate in terms of type, frequency, extent, site, and duration; d. Is not primarily for the economic benefit of the provider or primarily for the convenience of the client, caretaker, or provider; e.

Is not experimental or investigational; and g. E For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.

Be appropriate and effective to the comprehensive profile e. Be primarily directed to treat the diagnosed medical condition or the effects of the condition on the member, in all settings for normal activities of daily living. Be the least costly, appropriate, available health service alternative, and will represent an effective and appropriate use of program funds. Be the most appropriate care or service that can be safely and effectively provided to the member, and will not duplicate other services provided to the member.

Be sufficient in amount, scope and duration to reasonably achieve its purpose. Be recognized as either the treatment of choice i. Be rendered in response to a life threatening condition or pain, or to treat an injury, illness, or other diagnosed condition, or to treat the effects of a diagnosed condition that has resulted in or could result in a physical or mental limitation, including loss of physical or mental functionality or developmental delay.

Georgia Georgia Code Illinois Section Iowa Iowa Rule — Appropriate and necessary for the symptoms, diagnosis or treatment of the condition of the member; 2. Provided for the diagnosis or direct care and treatment of the condition of the member to enable the member to make reasonable progress in treatment; 3. Within standards of professional practice and given at the appropriate time and in the appropriate setting; 4.

To be medically necessary or a medical necessity, a covered benefit shall be: 1. Reasonable and required to identify, diagnose, treat, correct, cure, palliate, or prevent a disease, illness, injury, disability, or other medical condition, including pregnancy; 2. Appropriate in terms of the service, amount, scope, and duration based on generally-accepted standards of good medical practice; 3. Provided in the most appropriate location, with regard to generally-accepted standards of good medical practice, where the service may, for practical purposes, be safely and effectively provided; 5.

Alabama Telemedicine Telehealth Reimbursement Overview. Written informed consent is required prior to an initial telemedicine service. Alabama Medicaid reimburses for live video for the following services: Procedure codes covered for telemedicine services include; consultations , , office or other outpatient visits.

Maximum units for daily and annual limits are noted for each covered service. Due to the Medicaid inpatient reimbursement methodology it shall be necessary for a hospital.

Checklist for Psychologists - Information on denials, reasons for recoupments, where to find information in the Medicaid Provider Billing Manual, free tools and contacts for providers to use in preventing fraud and.

Medicaid Chapter X Supp. B purchased products shall bill no more than AAC.