Alabama Administrative Code Title 560 - ALABAMA MEDICAID AGENCY
Alabama Administrative Code – Title 560: Alabama Medicaid Agency
Title 560 contains the regulations governing the administration, eligibility, benefits, and provider requirements for the Alabama Medicaid Agency—the state agency responsible for managing Medicaid programs in Alabama.
🔹 Key Sections of Title 560
1. Agency Organization and Definitions
Establishes the authority, purpose, and structure of the Medicaid Agency.
Definitions of key terms used in Medicaid policy and regulations.
2. Eligibility and Enrollment
Criteria for Medicaid eligibility (income limits, categorical eligibility).
Application procedures and verification requirements.
Special eligibility categories (children, pregnant women, elderly, disabled).
3. Covered Services and Benefits
Descriptions of Medicaid-covered medical, dental, behavioral health, and long-term care services.
Limits and restrictions on coverage.
Prior authorization and service authorization rules.
4. Provider Participation and Requirements
Procedures and qualifications for providers to enroll and participate in Medicaid.
Billing, claims submission, and reimbursement policies.
Provider responsibilities, compliance, and audits.
5. Managed Care Programs
Rules governing managed care contracts and delivery systems.
Requirements for managed care organizations (MCOs).
Member rights and responsibilities under managed care.
6. Fraud, Abuse, and Program Integrity
Procedures for detecting, investigating, and penalizing Medicaid fraud and abuse.
Provider sanctions and penalties.
Recovery of overpayments.
7. Appeals and Hearings
Rights of applicants and recipients to appeal adverse decisions.
Procedures for fair hearings and resolution of disputes.
8. Special Programs
Medicaid waivers (e.g., home and community-based services).
Programs for specific populations (e.g., Medicaid for children with special health care needs).
📌 Common Uses of Title 560:
Understanding Medicaid eligibility requirements.
Provider enrollment and billing guidance.
Reviewing covered services and limitations.
Navigating appeal rights and procedures.
Learning about managed care participation.
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