Alabama Administrative Code Chapter 560-X-49 — Certified Nurse Practitioner Program

560 Alabama Medicaid Agency

Ala. Admin. Code r. 560-X-49-.01 General

(1) Nurse practitioners who are certified by the appropriate national organization as a family nurse practitioner, pediatric nurse practitioner, women’s health care practitioner, or neonatal nurse practitioner are eligible to participate in the Alabama Medicaid Program.

(2) A nurse practitioner who is employed by and reimbursed by a facility that receives reimbursement from the Alabama Medicaid Program for services provided by the nurse practitioner (i.e. hospital, rural health clinic, etc.) may not enroll, if their services are already being paid through that facility's cost report.

History

• Author: Elizabeth Huckabee, Associate Director, Medical Services
• Authority: State Plan; Attachment 3.1A, Section 6405 Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239); Title XIX, Social Security Act.
• Emergency rule effective May 22, 1991. Permanent rule effective September 11, 1991. Amended: Filed December 9, 2010; effective May 13, 2011. Amended: Filed August 9, 2019; effective September 23, 2019.

Ala. Admin. Code r. 560-X-49-.02 Participation

(1) In order to participate in the Alabama Medicaid Program, a nurse practitioner must complete an enrollment application which is obtained from the Agency's Fiscal Agent.

(2) The completed application must be returned to the Fiscal Agent for processing along with the following information:

(a) Proof of current Alabama registered nurse licensure card.

(b) Copy of current certification as a certified registered nurse practitioner in the appropriate area of the practice, family, pediatric or neonatal from a national certifying agency recognized by Medicaid.

(3) Once enrolled, the covered services that are provided by the nurse practitioner must be billed under his/her own provider number.

History

• Author: Debra Moore
• Authority: Title XIX, Social Security Act; 42 C.F.R., §431.51, and §431.107 State Plan.
• Emergency rule effective May 22, 1991. Permanent rule effective September 11, 1991. Amended: Filed October 6, 1997; effective November 10, 1997.

Ala. Admin. Code r. 560-X-49-.03 Reimbursement

(1) Nurse practitioners may only bill and be directly reimbursed for those services that are listed in the provider billing manual.

(2) In order for services to be covered, nurse practitioners must be under the supervision of a licensed physician.

History

• Author: Debra Moore
• Authority: State Plan, Attachment 3.1-A, Section 6405 Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239); Title XIX Social Security Act; 42 C.F.R. §431.51; Code of Ala. 1975, §34-21-1.
• Emergency rule effective May 22, 1991. Permanent rule effective September 11, 1991.

Ala. Admin. Code r. 560-X-49-.04 Limitations On Services

Limitations on services provided by nurse practitioners are the same as those for a physician and will be counted in the physician visit quota. See Rule 560-X-6-.14.

History

• Author: Debra Moore
• Authority: Title XIX, Social Security Act; State Plan, Attachment 3.1-A, 42 C.F.R. §440.230.
• Emergency rule effective May 22, 1991. Permanent rule effective September 11, 1991.

Ala. Admin. Code r. 560-X-49-.05 Billing Recipients

A nurse practitioner may bill Medicaid recipients for the copay amount, for Medicaid noncovered services and for services provided to a recipient who has exhausted his/her yearly limitations. Conditional collections to be refunded post payment by Medicaid and partial charges for balance of Medicaid allowed reimbursement are not permissible. Billing recipients for services not paid by Medicaid due to provider correctable errors on claims submission or untimely filing is not permissible.

History

• Author: Debra Moore
• Authority: 42 C.F.R. §447.15; State Plan, Attachment 4.18A; Title XIX, Social Security Act.
• Emergency rule effective May 22, 1991. Permanent rule effective September 11, 1991.

Ala. Admin. Code r. 560-X-49-.06 Third Party Requirements

Nurse practitioners are required to identify recipients who are covered by third party resources and to obtain payment from those resources in accordance with Chapter 20 of the Medicaid Administrative Code.

History

• Author: Debra Moore
• Authority: Title XIX, Social Security Act; 42 C.F.R. §1902(a)(25),401, Social Security Act; Code of Ala. 1975, §22-6-6.
• Emergency rule effective May 22, 1991. Permanent rule effective September 11, 1991.

Ala. Admin. Code r. 560-X-49-.07 Copayment (Cost-Sharing)

(1) Medicaid recipients are required to pay, and nurse practitioners are required to collect, the designated copayment amount on each visit. The copayment amount does not apply to services provided for the following:

(a) Pregnancy

(b) Nursing home residents

(c) Inpatient hospital visits

(d) Recipients under 18 years of age

(e) Surgery fees

(f) Physical therapy

(g) Family planning

(2) A provider may not deny services to any eligible individual due to the individual's inability to pay the cost-sharing amount imposed.

History

• Author: Debra Moore
• Authority: Title XIX, Social Security Act; State Plan, Attachment 3.1-A, 42 C.F.R. §440.230.
• Emergency rule effective May 22, 1991. Permanent rule effective September 11, 1991.