1. (1) Medicaid will utilize Alabama Medicaid Adult and Pediatric Inpatient Care Criteria (SI/IS) for utilization review, billing and reimbursement purposes.

   1. (a) It is the hospital’s responsibility to utilize its own physician advisor.
   2. (b) The attending physician and/or resident may change an order up to 30 days after discharge, as long as the patient met criteria for inpatient or observation services.
   3. (c) Refer to Chapter 3 of this Administrative Code for the fair hearings/appeals process.
2. (2) A percentage of admissions and concurrent stay charts will be reviewed by the Alabama Medicaid Agency and a Quality Improvement Organization contracted by the Agency.
3. (3) All in-state and border hospitals must submit Medical Care Evaluation (MCE) Studies (i.e. Performance Improvement Studies) and Utilization Review (UR) Plans to the contracted Quality Improvement Organization every year upon request.

Author: Solomon Williams, Associate Director, Institutional Services

Statutory Authority: State Plan; 42 C.F.R. 456, Subpart C; Section 1902 (d), Title XIX, Social Security Act.

History: Emergency rule effective April 1, 1983. Permanent rule effective July 8, 1983. Repealed effective October 12, 1988. New Rule: Filed May 12, 2010; effective June 16, 2010. Amended: Filed July 12, 2018; effective August 26, 2018.