Alabama Medicaid Agency Alabama Medicaid Agency Medicaid Covered Services

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Alabama Medicaid Agency Alabama Medicaid Agency Medicaid Covered Services Powered By Docstoc
					Alabama Medicaid Agency

Medicaid Covered Services For
 Recipients Who Have Full
     Medicaid Benefits
Benefits & Limitations With Copay
• Doctor Services - 14 Per Calendar Year
• Hospital Services - Inpatient - 16 Per
     Calendar Year ($50)
• Hospital Services - Outpatient - 3 Per
     Calendar Year ($3)
• Anesthesia - Approved When Medical
     Procedure is a Covered Service
Benefits & Limitations With Copay

• Ambulatory Surgical Centers - 3 Per
      Calendar Year ($3)
• Prescription Drugs (50 cents to $3 Per
• Rural Health Clinics ($1)
• Health Care Centers ($1)
• Certified Emergencies Are Not Limited
No Copayment Required For:
     Radiation Treatments
     Certified Emergencies
       Less Than 18 YO
       Family Planning
     LTC - Nursing Home
 Benefits & Limitations Continued

• Physician’s May Submit for Laboratory
  Work Done by Them in Their Own Office,
  if Not, May Submit for Specimen
  Collection Fee (36415-90)

• No Copay for Laboratory & X-ray
   Benefits & Limitations Continued
• Prescription Drugs - Most Prescribed Drugs
    and Many OTC Drugs Are Covered (Use
    Generic if Available)
• Health Information Designs - Overrides and
    Prior Approves Drugs (800-748-0130)
• Up to 30-day Supply
• Non-injectable Medications Must be Billed
    by a Pharmacy to Be Covered
        Benefits & Limitations Continued
•   Physician’s May Bill for Drugs Given IM
    and Site-Specific Injections (Appendix H)
•   Reimburse Separately for Cancer
    Chemotherapy Injections (IM, IV, IA, SQ)
    in Addition to an OV
•   Chemotherapy in an Inpatient Setting is
    Considered a Non-covered Service
•   The Professional Component for
    Chemotherapy is Considered a Non-covered
 Non-Emergency Transportation
• Helps Cover the Cost of Transportation to
  and From Medically Necessary
  Appointments When There Is No Other
  Way to Get to Their Appointments
• Call 10-14 Working Days in Advance:
             (800) 204-3728
Breast Reconstruction Surgery Guidelines
• Requires Prior Authorization
• Following a Medically Necessary
• When Performed for the Removal of Cancer
• When Recipient Elects Reconstruction
  Within Two Years of the Mastectomy
• When the Recipient is Eligible for Medicaid
  on the Date of Reconstruction Surgery
     Breast Reconstruction Surgery
         Guidelines Continued
• In the Manner Chosen by the
  Patient/Physician in Accordance With
  Guidelines Consistent With Medicare and
  Other Third Party Payers
• Appropriate Diagnosis Codes Used When
  Filing Claims
Breast Reconstruction Surgical
         PCs (CPT)

  •   19340      •   19364
  •   19342      •   19366
  •   19350      •   19367
  •   19357      •   19368
  •   19361      •   19369
External Breast Prostheses Guidelines
•Requires Prior Authorization
•Coverage is Available for Either an
Approved External Prostheses or Breast
•External Breast Prostheses Following
Mastectomy for Breast Cancer are Covered
for All Medicaid Eligible Recipients
Meeting Established Medical Criteria (Same
Criteria as Breast Reconstruction Surgery)
   External Breast Prostheses Continued
• Must be Eligible for DOS of Provision of
• Date of Mastectomy and Diagnosis Code
  (174.0-174.9, 198.81, 233.0 of ICD-9) must
  Be Provided in the Clinical Statement of
  Form 342 (Prior Review & Authorization)
• Appropriate PCs are Billed
• Once Breast Reconstruction has been
  Performed External Breast Prostheses are
      External Breast Prostheses PCs
• L8000 bra 6/Year    • L8030 silicone or
                        equal prosthesis
• L8015 garment         2/Year
  2/Year              • L8035* custom
                        prosthesis, molded
• L8020 mastectomy    • L8039* not otherwise
  form prosthesis       classified prosthesis
                      *Reviewed case-by-case
       External Breast Prostheses

• Required Documentation Should Be
  Attached to Form 342 and Submitted to
  Electronic Data Systems (EDS) Prior to
  Providing Prosthesis
• External Breast Prostheses are Considered
  DME. Please Be Sure the DME is Enrolled
  and Accepts Medicaid
           Reference Tools
• Website: “”
• Provider Billing Manual
        Appendix H
• Provider Insider (Provider Newsletters)
        July 2001 for Breast Prostheses
• Provider Notices
        Breast Reconstruction Surgery 00-04