CurrentAlabama MedicaidPolicy 560-X-2-.01
Methods for Assuring High Quality Care
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Defines methods Alabama Medicaid will use to ensure medical care and services are high quality, properly utilized, and compliant with professional standards and applicable laws; applies to Alabama Medicaid Agency operations, providers, recipients, fiscal agents, and related committees.
Policy Summary
PayerAlabama Medicaid
PolicyMethods for Assuring High Quality Care
Policy CodePolicy 560-X-2-.01
Change TypeNo material changes
Effective DateJul 14, 2025
Last ReviewMay 30, 2025
Next Review DateN/A
Key ActionPrior authorization requests from optometrists denied by Medicaid must be submitted to the Optometric Peer Review Committee for consultation before a final determination is made.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
Peer Review CommitteesQuality oversight bodies described
QuarterlyMAC meeting frequency
QuarterlyBAC meeting frequency
2+ yrsPayment-rate advisory meeting frequency
BiannualOptometry committee frequency
Key Definitions
Methods for Assuring High Quality Care - definition
DefinitionMethods used to administer the Medical Assistance Program to ensure medical remedial care and services are of high quality, properly utilized, and based on acceptable professional medical standards, State and Federal laws and regulations.
PurposeEnsure services are properly utilized through utilization review, monitoring, and professional review programs for hospitals, nursing facilities, dental, pharmacy, and home health services.
ScopeApplies to Alabama Medicaid Agency operations, providers, recipients, fiscal agents, and designated designees responsible for review and monitoring activities.
Key mechanismsUtilization review plans approved by Medicaid or its designee; monitoring of facility utilization review for inpatient and extended care; involvement of professional review programs for dental and pharmacy services.
Peer Review Committees - definition
DefinitionIndependent committees established in Alabama to settle disputes related to charges for professional and other medical assistance services.
Origins of referralsProblems may be submitted by the Alabama Medicaid Agency, its fiscal agent, providers, or recipients after attempts to resolve via claims processing and Agency review.
Independence and conflict rulesCommittees act independently of the fiscal agent and Agency representatives; members with ownership interests or direct professional responsibility in a reviewed case must not participate.
Decision finalityA Peer Review Committee decision is final and binding if approved by the Director, Programs, Alabama Medicaid Agency.
Process notesMedicaid assembles facts and arranges committee consideration at a mutually agreeable time; professional specialty consultation may be arranged when needed.
Medicaid Advisory Committee (MAC) - definition and role
AuthorityAdvisory body established in accordance with 42 CFR § 431.12 to provide guidance and recommendations to Alabama Medicaid and the Medicaid Commissioner.
RoleAdvise on policy development, program administration, and delivery of health and medical care services to ensure accessibility and quality for Medicaid recipients.
Meeting frequencyShall meet quarterly with at least two meetings per year open to the public.
Decision statusDecisions are recommendations only and do not constitute Agency decisions.
GovernanceMembership appointed by the Medicaid Commissioner; bylaws, regular meeting schedule, and Annual Report will be published on the Agency website.
Beneficiary Advisory Council (BAC) - definition and meeting requirement
DefinitionA forum established in accordance with 42 CFR § 431.12 for Medicaid recipients, their families, and caregivers to share experiences and provide direct feedback to Alabama Medicaid.
PurposeProvide input related to policy development and effective administration of the Medicaid program to ensure affected persons' voices are heard.
Meeting requirementShall meet quarterly and must meet separately and in advance of each MAC meeting to prepare BAC members for MAC participation.
Decision statusDecisions are recommendations only and are not binding on Alabama Medicaid.
GovernanceMembership appointments by the Medicaid Commissioner; bylaws and meeting schedule will be published on the Agency website.
Interested Parties Advisory Group - definition and remit
DefinitionAn interested parties advisory group established under 42 CFR § 447.203(b)(6) to advise Alabama Medicaid on payment rates for direct care workers (personal care, home health aide, homemaker, and habilitation services).
Meeting frequencyShall meet at least every two years.
RemitMake recommendations on the sufficiency of State Plan, 1915(c) waiver, and demonstration direct care worker payment rates as applicable.
Decision statusDecisions are recommendations only and are not binding on Alabama Medicaid.
GovernanceMembership appointments by the Medicaid Commissioner; detailed bylaws and recommendations will be published on the Agency website.
Quality Assurance and Utilization Review Requirements
Quality assurance and utilization review requirements
Procedures and responsibilities established for quality assurance and utilization review include:
Providers and institutions must have a utilization review plan approved by Medicaid or its designated agent.
Medicaid or its designee will monitor facility utilization review activities for inpatient hospital and extended care services.
Utilization review for dental services is conducted as part of the dental professional review program; pharmaceutical services are monitored through the Drug Utilization Review Program in cooperation with the fiscal agent.
Medicaid monitors utilization review activities related to evaluation and supervision of nursing and other services provided by home health agencies.
Medical review responsibility: Medicaid or its designee is responsible for medical review for hospitals; Alabama Medicaid Agency is responsible for medical review for skilled and intermediate care nursing facilities (including ICF/IID).
Problem referral process: the fiscal agent will gather information from claims processing and attempt resolution with provider/recipient; unresolved issues are submitted to Alabama Medicaid; matters not resolved by Alabama Medicaid may be referred to the appropriate Peer Review Committee.
Peer Review Committee rules: committees act independently of the fiscal agent and Agency representatives; members with ownership interest in a facility under review or with a conflict (attending physician, partner, or associate) must not participate in that review; committees may obtain specialty consultation; a majority constitutes a quorum; reports are sent to Deputy Commissioner Program Administration and released on a need-to-know basis; a committee decision is final and binding if approved by the Director, Programs, Alabama Medicaid Agency.
Optometric Peer Review Committee: maintained by Medicaid, meets at least twice yearly and serves as an appeal body; prior authorization requests from optometrists denied by Medicaid shall be submitted for consultation to the Peer Review Committee before a final determination is made.
Advisory bodies and governance: Medicaid Advisory Committee (MAC), Beneficiary Advisory Council (BAC), Interested Parties Advisory Group, and Quality Assurance Committees provide recommendations and guidance; the MAC will meet quarterly (at least two public meetings per year), its decisions are advisory only, membership and bylaws will be publicly posted, and BAC meets separately and in advance of each MAC meeting.
Provider Actions and Referral Procedures
Prior Authorization
Submit denied optometrist prior authorizations to peer review
Prior authorization requests from optometrists that are denied by Medicaid must be submitted to the Optometric Peer Review Committee for consultation before a final determination is made.
- The Optometric Peer Review Committee is maintained by Medicaid and meets at least twice each calendar year.
- The Committee functions as an appeal body for requests from Medicaid, optometric providers, and Medicaid recipients.
Policy Summary
PayerAlabama Medicaid
PolicyMethods for Assuring High Quality Care
Policy CodePolicy 560-X-2-.01
Change TypeNo material changes
Effective DateJul 14, 2025
Last ReviewMay 30, 2025
Next Review DateN/A
Key ActionPrior authorization requests from optometrists denied by Medicaid must be submitted to the Optometric Peer Review Committee for consultation before a final determination is made.
SourceLink
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