Outpatient Renal Dialysis (ESRD) Services Coverage Criteria
Customize your policy alerts
Sign up for all Alabama Medicaid policy alerts
Know when Alabama Medicaid releases new policies or updates existing guidance.
Monitor payer policy activity
Rules governing Medicaid coverage, facility participation, and billing for outpatient maintenance dialysis (hemodialysis and peritoneal dialysis) provided to eligible Alabama Medicaid recipients.
No material clinical or coverage changes in this revision.
Coverage Criteria for Outpatient Dialysis
Coverage for Outpatient Maintenance Dialysis
Covered when ALL of the following are met:
Laboratory testing sites furnishing services to Medicaid recipients must be CLIA certified at the level of testing provided. Laboratories that do not meet CLIA certification standards are not eligible for reimbursement for laboratory services from the Alabama Medicaid Program.
Routine parenteral items and routine drugs or injectables administered in conjunction with dialysis procedures are included in the facility composite rate and shall not be billed separately. The composite rate also includes administration fees for injectables and common dialysis elements such as overhead, personnel, equipment, supplies, use and maintenance of the dialysis machine, routine ESRD-related laboratory tests, and certain injectables (for example, heparin and its antidote).
The policy does not list any items explicitly designated as not medically necessary; services and supplies not covered would be those specifically excluded or not meeting the stated coverage criteria.
Coding, Limits, and Reimbursement Units
| 5-76061 | Bone Survey - annually (roentgenographic method or photon absorptiometric procedure for bone mineral analysis) |
| 5-71020 | Chest X-ray - every six months |
| 6-95900 | Nerve Conductor Velocity Test (Peroneal NCV) - every three months |
| 6-93000 | EKG - every three months |
Provider Enrollment, Billing, and Operational Rules
Enrollment requirement for coverage — Medicaid-enrolled ESRD facility
Maintenance dialysis treatments are covered only when provided by a Medicaid-enrolled ESRD hospital-based renal dialysis center or free-standing ESRD facility; reimbursement will be based on a composite rate consisting of the treatment elements (overhead, personnel, equipment/supplies, dialysis machine use and maintenance, ESRD-related lab tests, certain injectable drugs and biologicals).
- Services must be provided by a Medicaid-enrolled ESRD facility to receive Medicaid payment
- Reimbursement is by a composite rate that includes routine dialysis elements and specified routine labs and injectables
Step therapy — none specified
No step-therapy requirements are specified in this policy.
Facility enrollment and contracting — submit letter and execute contract
ESRD facilities and any satellites/subunits must submit a letter requesting enrollment and execute a contract with the Alabama Medicaid Agency; satellites/subunits must be separately approved and execute their own contract.
- Submit a letter requesting enrollment to participate in Title XIX Medicaid.
- Execute a contract with the Alabama Medicaid Agency; satellites/subunits require separate approval and their own contracts.
Billing and recipient notices — do not bill for covered services
Providers must not bill eligible Medicaid recipients for covered services; providers may send an outstanding-claim notice only if it is clearly labeled in bold 'THIS IS NOT A BILL.' Follow-up on unpaid claims is the provider’s responsibility, and providers may bill recipients only for noncovered services.
- Do not bill or send statements for covered services once the recipient is accepted as a Medicaid patient.
- If sending a notice about an outstanding claim, include the statement in bold: 'THIS IS NOT A BILL.'
- Follow up with the fiscal agent and/or Medicaid on unpaid claims—do not require the recipient to resolve claim issues.
- Providers may bill recipients only for explicitly noncovered services.
Lab CLIA noncompliance — lack of CLIA certification disqualifies reimbursement
Laboratory testing sites providing services to Medicaid recipients must be CLIA certified for the level of testing performed; laboratories that do not meet CLIA certification standards are not eligible for reimbursement for laboratory services.
- Providers are responsible to assure Medicaid that all CLIA regulations are adhered to and to provide waiver certification numbers as applicable.
- Non‑CLIA‑certified laboratories are ineligible for reimbursement.
Background
End Stage Renal Disease (ESRD) services under this rule are outpatient maintenance dialysis services provided by Medicaid-enrolled free-standing ESRD facilities or hospital-based renal dialysis centers. Hemodialysis is defined as extracorporeal removal of waste via diffusion across a semipermeable membrane and is limited to 156 sessions per year (equivalent to three sessions per week). Peritoneal dialysis (CAPD and CCPD) is performed inside the body, furnished on a continuous basis, and is reimbursed at a daily rate. Reimbursement for covered dialysis treatments is based on a composite rate that includes routine dialysis elements, routine labs, and certain injectables; nonroutine tests and procedures must be billed separately by the actual provider of service.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.