Alabama Administrative Code Chapter 560-X-21 — Nurse Midwife Program

560 Alabama Medicaid Agency

Ala. Admin. Code r. 560-X-21-.01 Legal Authority For The Nurse Midwife Program

(1) Alabama Law provides rules under which properly trained nurses can be licensed to practice the profession of Nurse Midwifery. (Code of Ala. 1975, §§34-19-2, et seq.)

(2) Federal Law [Title XIX, Sections 1905(a)(17) and (m)] requires that the Medicaid Program in each state include the services of nurse midwives as a mandated service.

(3) These regulations state the conditions under which the services of nurse midwives are covered by the Medical Assistance Program of the Alabama Medicaid Agency.

History

• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§440.210, 440.165, 441.220, and 441.21. Code of Ala. 1975, §§34-19-2, et seq.
• Rule effective October 1, 1982. Emergency amendment June 14, 1993. Amended: August 12, 1993. Amended: Filed February 7,1994; effective March 15, 1994.

Ala. Admin. Code r. 560-X-21-.02 General

(1) Providers in this program are limited to persons who are licensed as "Registered Nurse" and who are also licensed as "Certified Nurse Midwife."

(2) Nurse Midwifery practice is defined as the management of care for normal healthy women and their babies in the areas of prenatal; labor and delivery; postpartum care; well-woman gynecology, including family planning services; and normal newborn care.

(3) The practice of Nurse Midwifery must be done under appropriate physician supervision.

(4) The services provided by nurse midwives must be within the scope of practice authorized by state law and regulations.

History

• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§440.165, and 441.21. Code of Ala. 1975, §§34-19-2, et seq.
• Rule effective October 1, 1982. Emergency amendment June 14, 1993. Amended August 12, 1993. Amended: Filed February 7,1994; effective March 15, 1994.

Ala. Admin. Code r. 560-X-21-.03 Provider Participation

(1) In order to participate in the program a nurse midwife must submit a completed application form along with a copy of current registered nurseand nurse midwife licensure, plus copy of the written signed agreement between the nurse midwife and the physician consultant. If the application isapproved, Medicaid will offer the applicant a one year renewable contract.

(2) Only in-state and border line out-of-state (within a 30-mile radius of Alabama's state line) providers who meet enrollment requirements areeligible to participate in the Alabama Medicaid Program.

(3) Nurse Midwives who want to participate in the Medicaid program should contact the Medicaid Agency for an enrollment application. Send therequest to:

Administrator of Nurse Midwife Program

Alabama Medicaid Agency

501 Dexter Avenue

P. O. Box 5624

Montgomery, Alabama 36103-5624

History

• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, et seq., 440.165, 441.21; Code of Ala. 1975, §§34-19-2, etseq.
• Rule effective October 1, 1982. Effective date of this emergency amendment June 14, 1993. Effective date of this amendment August12, 1993. Amended Filed: July 6, 1995; effective August 12, 1995.

Ala. Admin. Code r. 560-X-21-.04 Reimbursement

(1) Nurse midwives may submit claims and be reimbursed only for those procedure codes authorized by Medicaid policy. Claims should be submitted on a Health Insurance (HCFA 1500) Claim Form.

(2) The nurse midwife agrees when billing Medicaid for a service that the midwife will accept as payment in full, the amount paid by Medicaid for the services and that no additional charges will be made.

(3) Conditional collections from patients, made before Medicaid pays, to be refunded after Medicaid reimbursement for the service, are not permissible.

(4) A hospital-based nurse midwife who is employed by and paid by a hospital may not bill Medicaid for services performed therein and for which the hospital is reimbursed. A nurse midwife who is not employed by and paid by a hospital may bill Medicaid using a Health Insurance (HCFA1500) Claim Form. To prevent double payment, the nurse midwife having a Medicaid provider number(s) shall inform the Alabama Medicaid Agency of the name of the hospital(s) with whom employed, regardless of regularity and frequency.

History

• Author: Glen A. Smythe
• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§440.165, 440.210, 440.220, 441.21; Code of Ala. 1975, §§34-19-2, et seq.
• Rule effective October 1, 1982. Amended effective July 10, 1987; February 9, 1989. Emergency amendment June 14, 1993.Amended August 12, 1993. Amended: Filed February 7, 1994; effective March 15, 1994.

Ala. Admin. Code r. 560-X-21-.05 Covered Services

(1) The maternity services normally provided in maternity cases include antepartum care, delivery, and postpartum care. When a nurse midwife provides total obstetrical care, the procedure code which shall be filed on the claim form is the code for all inclusive "global" care. The indicated date of service on "global" claims should be the date of delivery. If a woman is pregnant at the time she becomes eligible for Medicaid benefits,only those services provided during the time she is eligible will be covered. When a nurse midwife provides eight (8) or more prenatal visits,performs the delivery, and provides postpartum care, he/she shall use a "global" obstetrical code in billing the services. If a nurse midwife submits a"global" code for maternity services, the visits covered by this code are not counted against the recipient's limit of physician office visits per calendar year. For purposes of "global" obstetrical billing, services rendered by members of a group practice are to be considered as services rendered by a single provider.

(a) Antepartum care includes all usual prenatal services such as initial office visit, at which time the pregnancy is diagnosed, initial and subsequent histories, physical examinations, blood pressure recordings, fetal heart tones, maternity counseling, etc.; therefore, additional claims for routine services shall not be filed. Antepartum care also includes routine lab work (i.e.; hemoglobin, hematocrit, and chemical urinalysis); therefore,additional claims for routine lab work should not be filed.

1. In order to bill for Antepartum Care Only services, nurse midwife providers must utilize the antepartum procedure codes when billing for theservices. Antepartum Care Only services do not count against the recipient's annual office visit benefit limits. When less than four antepartum visits are provided, the nurse midwife will use office visit procedure codes to bill for the services. The office visit procedure codes will be counted against the recipient's annual office visit benefit limit.

(b) Delivery shall include vaginal delivery (with or without episiotomy) and postpartum care or vaginal delivery only services. The nurse midwife will utilize the appropriate CPT code when billing delivery services. More than one delivery fee may not be billed for a multiple birth (i.e.; twins,triplets, etc.). Delivery fees include all professional services related to the hospitalization and delivery services provided by the nurse midwife.Additional claims for the nurse midwife's services in the hospital (e.g., admission) may not be filed.

EXCEPTION: When a nurse midwife's first and only encounter with the recipient is for delivery ("walk-in" patient) he/she may bill for a hospital admission (history and physical) in addition to delivery charges.

(c) Postpartum care includes office visits following vaginal delivery for routine postpartum care within sixty (60) days post delivery. Additional Claims for routine visits during this time should not be filed.

(2) Family planning services include services that prevent or delay pregnancy such as office visits for evaluation and management of contraceptive issues, including procedures and supplies as appropriate for effective birth control. Nurse midwives are not authorized to do sterilization procedures. Other surgical procedures; such as diaphragm fittings, IUD insertions or removals, and contraceptive implant procedures; are covered when provided according to state laws and regulations.

(3) The nurse midwife may provide and be reimbursed for well-woman gynecological services including the evaluation and management of common medical and/or gynecological problems such as menstrual problems, Pap smear screening, menopausal and hormonal treatments,treatment of sexually transmitted diseases, and treatment of minor illnesses (e.g., a minor pelvic inflammatory disease).

History

• Author: Glen A. Smythe
• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R., §§440.165, 440.210, 440.220, 441.21; Code of Ala. 1975, §§34-19-2, et seq.
• Emergency rule June 14, 1993. Effective August 12, 1993. Amended: Filed February 7, 1994; effective March 15, 1994. Amended:Filed July 6, 1995; effective August 12, 1995.

Ala. Admin. Code r. 560-X-21-.06 Required Written Records

(1) When a patient is accepted for monthly services, the midwife's care must include plans for a delivery to be accomplished in a licensed hospital.In an emergency, delivery may be accomplished elsewhere. The plans need not be submitted to Medicaid but the midwife's file should contain written evidence that such plans existed for each patient accepted for global care.

(2) All nurse midwife services must be rendered under appropriate physician supervision. The physician may not bill for these supervisory services.The written records that each midwife keeps should include records naming the physician(s) with whom she works, and stating the working arrangement with the physician. The statement of the working arrangement need not be a formal contract, but it must contain the signature of both parties and must show the date on which it was signed.

(3) A complete medical record shall be maintained for each recipient for whom the nurse midwife provides services.

History

• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§440.165, 440.210, 440.220, 441.21; Code of Ala. 1975, §§34-19-2, et seq.
• Rule effective October 1, 1982. Emergency rule June 14, 1993. Effective August 12, 1993. Amended: Filed February 7, 1994;effective March 15, 1994.

Ala. Admin. Code r. 560-X-21-.07 Payments To Physicians

(1) The supervising physician may not bill for supervisory services. The physician can bill Medicaid, however, if it becomes necessary for the physician to perform the delivery or complete a delivery service for the nurse midwife. When the physician bills the delivery only service, the midwife may bill antepartum care or postpartum care, or both, depending on which service(s) the nurse midwife performed. If the physician bill for delivery only including postpartum care, the nurse midwife may bill only for the antepartum care provided.

(2) Sterilization at the time of delivery is covered by Medicaid only if it is performed by the physician, and only if all other Medicaid requirements for sterilization are met.

History

• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §441.21; Code of Ala. 1975, §§34-19-2, et seq.
• Rule effective October 1, 1982. Emergency amendment June 14, 1993. Amended August 12, 1993. Amended: Filed February 7,1994; effective March 15, 1994.

Ala. Admin. Code r. 560-X-21-.08 Third Party Requirements

(1) Nurse Midwives 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 Agency's Administrative Code.

History

• Authority: State Plan; Title XIX, Social Security Act; §1902(a)(25); 42 C.F.R. §441; Code of Ala. 1975, §§22-6-6, et seq.
• Effective date of this emergency amendment June 14, 1993. Effective date of this amendment August 12, 1993.

Ala. Admin. Code r. 560-X-21-.09 Billing Of Medicaid Recipients

(1) Refer to Chapter 1 of this Code for general information regarding providers billing Medicaid recipients.

(2) Medicaid recipients are exempt from co-payment requirements for maternity care and family planning services.

(3) Co-pay requirements apply to well-woman gynecological office services, except for those recipients under the age of 18.

History

• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§447.15, et seq.
• Emergency amendment June 14, 1993. Amended August 12, 1993. Amended: Filed February 7, 1994; effective March 15, 1994.Amended: Filed July 6, 1995; effective August 12, 1995.