Utilization Management and Bill Screening

In accordance with Code of Alabama, 1975, §25-5-293(k), the Alabama Department of Labor has filed for adoption Alabama Department of Labor Administrative Code Rules 480-5-5-.01 through .37, Utilization Management and Bill Screening. The initial effective date of these rules was September 12, 1996.


A definition of Utilization Management, Utilization Review, and Bill Screening follows:


Utilization Management is a comprehensive set of integrated components including: pre-certification review, admission review, continued stay review, retrospective review, discharge planning, bill screening and individual medical case management as required.

Utilization Review is the determination of medical necessity for medical and surgical in-hospital, outpatient, and alternative setting treatments for acute and rehabilitation care. It includes pre-certification for elective treatments. Concurrent review and, if necessary, retrospective review are required for emergency cases.

Bill Screening is the evaluation and adjudication of provider bills for appropriateness of reimbursement relative to medical necessity and prevailing rates of reimbursement, duplicate charges, unbundling of charges, relativeness of services to injury or illness, necessity of assistant surgeons, adjudication of multiple procedures, number of modalities, global procedures, and any other prevailing adjudication issues that may apply.


Utilization management and bill screening may be implemented, but is not required. If utilization management and bill screening is performed, Code of Alabama, 1975, §25-5-293(g) requires such services be performed by qualified individuals or entities.

Any self-insured employer, self-insured group fund, or insurance carrier that does not choose to perform utilization management and bill screening is requested to advise the Workers' Compensation Division in writing.

Each self-insured employer, self-insured group fund, insurance carrier or utilization review company that will perform utilization management and bill screening can download the application for certification.


UTILIZATION MANAGEMENT ADMINISTRATIVE RULES
Last Amended:
480-5-5-.01 SCOPE
480-5-5-.02 DEFINITIONS April 13, 2001
480-5-5-.03 TIMELY PAYMENT OF UNDISPUTED MEDICAL CLAIMS July 8, 2002
480-5-5-.04 STATEMENT OF SERVICES
480-5-5-.05 ENTITY QUALIFIED TO PERFORM BILL SCREENING July 25, 2011
480-5-5-.06 UTILIZATION REVIEW ENTITY QUALIFIED TO PERFORM UTILIZATION  REVIEWS
480-5-5-.07 UTILIZATION REVIEW PROCESS July 25, 2011
480-5-5-.08 PRE-CERTIFICATION REQUIRED August 18, 1997
480-5-5-.09 PROCEDURE FOR PRE-CERTIFICATION January 12, 2009
480-5-5-.10 CONTINUED STAY REVIEW PROCEDURES January 12, 2009
480-5-5-.11 TECHNICAL CONSIDERATIONS FORE REVIEW (BILL SCREENING) OF CLAIMS
480-5-5-.12 PHYSICIAN OF RECORD
480-5-5-.13 EMERGENCY CARE
480-5-5-.14 SECOND OR OPPOSING SURGICAL OPINION
480-5-5-.15 BILL SCREENING July 25, 2011
480-5-5-.16 CONFLICT OF INTEREST: HEALTH FACILITY OWNERSHIP BY A PROVIDER
480-5-5-.17 OPTOMETRIC SERVICES
480-5-5-.18 CHIROPRACTIC SERVICES
480-5-5-.19 PHYSICAL THERAPY/OCCUPATIONAL THERAPY/SPEECH THERAPY SERVICES
480-5-5-.20 HOSPITAL SERVICES
480-5-5-.21 PRESCRIBED MEDICATIONS January 12, 2009
480-5-5-.22 APPROVED STANDARDIZED MEDICAL REIMBURSEMENT FORMS April 1, 1998
480-5-5-.23 APPEALS PROCESS FOR UTILIZATION REVIEW BILL SCREENING, PEER  CLINICAL REVIEW AND DENIAL OR REVOCATION OF UTILIZATION REVIEW CERTIFICATE
480-5-5-.24 DISCHARGE PLANNING PROCEDURES
480-5-5-.25 ON-SITE AUDIT
480-5-5-.26 AMBULATORY SURGERY CENTERS January 12, 2009
480-5-5-.27 ADMISSION REVIEW PROCEDURES
480-5-5-.28 DENTAL SERVICES 
480-5-5-.29 MEDICAL CASE MANAGEMENT
480-5-5-.30 HOME HEALTH CARE SERVICES
480-5-5-.31 PAIN MANAGEMENT PROGRAM January 12, 2009
480-5-5-.32 DURABLE MEDICAL EQUIPMENT April 1, 1998
480-5-5-.33 TIME LIMITS FOR CLAIMS PAYMENTS August 18, 1997
480-5-5-.34 AMBULANCE SERVICES August 18, 1997
480-5-5-.35 IMPAIRMENT RATING GUIDE April 1, 1998
480-5-5-.36 TIME LIMITS FOR EMPLOYEE FILING INCURRED EXPENSE CLAIMS January 12, 2009
480-5-5-.37 OUT OF STATE MEDICAL PROVIDERS February 14, 2011
   

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