CurrentAlabama MedicaidPolicy N/A

Outpatient Renal Dialysis (ESRD) Services Coverage Criteria

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Rules governing Medicaid coverage, facility participation, and billing for outpatient maintenance dialysis (hemodialysis and peritoneal dialysis) provided to eligible Alabama Medicaid recipients.

Policy Summary

PayerAlabama Medicaid

PolicyOutpatient Renal Dialysis (ESRD) Services Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 1982

Last ReviewJan 14, 2025

Next Review DateN/A

Key ActionEnsure maintenance dialysis is provided by a Medicaid-enrolled ESRD facility and that the facility is enrolled and contracted with Alabama Medicaid.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

156Hemodialysis limit

Daily ratePeritoneal payment

CompositeReimbursement basis

CLIALab requirement

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CurrentAlabama MedicaidPolicy N/A

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.

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Rules governing Medicaid coverage, facility participation, and billing for outpatient maintenance dialysis (hemodialysis and peritoneal dialysis) provided to eligible Alabama Medicaid recipients.

Policy Summary

PayerAlabama Medicaid

PolicyOutpatient Renal Dialysis (ESRD) Services Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 1982

Last ReviewJan 14, 2025

Next Review DateN/A

Key ActionEnsure maintenance dialysis is provided by a Medicaid-enrolled ESRD facility and that the facility is enrolled and contracted with Alabama Medicaid.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

156Hemodialysis limit

Daily ratePeritoneal payment

CompositeReimbursement basis

CLIALab requirement

Coverage for Outpatient Maintenance Dialysis

Covered when ALL of the following are met:

Facility and enrollment: Services must be provided by a Medicaid-enrolled ESRD hospital-based renal dialysis center or free-standing ESRD facility; satellite units/subunits must be separately approved and execute a contract with the Alabama Medicaid Agency.

Service types and limits: Hemodialysis is covered and limited to 156 sessions per year (three sessions per week). Peritoneal dialysis (CCPD and CAPD) is covered; CCPD and CAPD are furnished continuously and will be paid at a daily rate rather than per treatment.

Reimbursement scope: Routine dialysis elements including overhead, personnel services, equipment and supplies, use and maintenance of the dialysis machine, ESRD-related routine laboratory tests, and routine parenteral items/administration fees (and certain injectables such as heparin and its antidote) are included in the facility composite rate and may not be billed separately; nonroutine injectables and nonroutine procedures must be billed by the actual provider of service.

Laboratory requirements: Routine laboratory tests listed for hemodialysis and CAPD are included in the composite rate; all laboratory testing sites providing services to Medicaid recipients must be CLIA certified to the level of complexity required, and laboratories not meeting CLIA standards are not eligible for reimbursement.

Billing to recipients: No eligible Alabama Medicaid recipient shall receive a bill for covered services once accepted as a Medicaid patient; providers may send an outstanding claim notice only if it clearly states in bold letters 'THIS IS NOT A BILL.' Providers are responsible for follow-up with Medicaid or the fiscal agent on unpaid claims and may bill recipients only for explicitly noncovered services.

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

Ancillary procedure codes (listed by internal numeric identifiers)mixed

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

Hemodialysis session limit — 156 sessions per year

Annual session limit156 hemodialysis sessions per year (equivalent to three sessions per week)

Weekly allowanceUp to 3 hemodialysis sessions per week

ScopeApplies to hemodialysis as defined by Alabama Medicaid for outpatient maintenance dialysis provided by Medicaid-enrolled ESRD facilities

Provider Enrollment, Billing, and Operational Rules

Prior Authorization

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

Note

Step therapy — none specified

No step-therapy requirements are specified in this policy.

Documentation Required

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 Rule

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.

Denial Risk

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

Definition — End Stage Renal Disease (ESRD) services

DefinitionOutpatient maintenance dialysis services provided by a free-standing ESRD facility or a renal dialysis center (hospital-based).

Provider requirementServices must be furnished by a Medicaid-enrolled ESRD hospital-based renal dialysis center or free-standing ESRD facility; satellites/subunits must be separately approved and contract with Medicaid.

Reimbursement basisRoutine dialysis elements (overhead, personnel, equipment, routine labs, certain injectables) are included in a composite rate

Definition — Hemodialysis (description and limits)

Hemodialysis descriptionRemoval of substances from the blood by diffusion across a semipermeable membrane while blood is circulated outside the body.

Hemodialysis limitLimited to 156 sessions per year (provides for three sessions per week).

Peritoneal dialysis overviewDialysis performed inside the body using the patient’s peritoneal membrane; removes waste products and excess fluids without extracorporeal circulation.

Peritoneal dialysis types & paymentCovered types: Continuous Cycling Peritoneal Dialysis (CCPD) — machine-assisted, and Continuous Ambulatory Peritoneal Dialysis (CAPD) — not machine-assisted. CCPD and CAPD are continuous (not discrete sessions) and are paid at a daily rate, not per treatment.

Outpatient Renal Dialysis (ESRD) Services Coverage Criteria

Sign up for all Alabama Medicaid policy alerts

Outpatient Renal Dialysis (ESRD) Services Coverage Criteria

Sign up for all Alabama Medicaid policy alerts

Coverage Criteria for Outpatient Dialysis

Coding, Limits, and Reimbursement Units

Provider Enrollment, Billing, and Operational Rules

Background

Definitions