471 Neb. Admin. Code, ch. 10, § 004

Current through June 17, 2024

Section 471-10-004 - SERVICE REQUIREMENTS

004.01GENERAL REQUIREMENTS.

004.01(A)MEDICAL NECESSITY. Services and supplies that do not meet the definition of medical necessity are not covered. The fact that the physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Nebraska Medicaid. Services and supplies which do not meet the definition of medical necessity set out above are not covered. Approval by the Food and Drug Administration or similar approval does not guarantee coverage by the Department. Licensure or certification of a particular provider type does not guarantee Nebraska Medicaid coverage.

004.01(B)PRIOR AUTHORIZATION. The Department requires that physicians request prior authorization from the Department before providing:

(1) Medical transplants;

(2) Abortions;

(3) Cosmetic and reconstructive surgery;

(4) Bariatric surgery for obesity;

(5) Out-of-State Services. Exception: Prior authorization is not required for emergency services;

(6) Established procedures of questionable current usefulness;

(7) Procedures which tend to be redundant when performed in combination with other procedures;

(8) New procedures of unproven value;

(9) Certain drug products;

(10) Sleep study for a child under the age of six years old; and

(11) Ventricular Assist Device.

004.01(B)(i)PRIOR AUTHORIZATION PROCEDURES. The physician must request prior authorization for these services in writing, or by using the standard electronic Health Care Services Review.

004.01(B)(i)(1)REQUEST FOR ADDITIONAL EVALUATIONS. The Department may request, and the provider must submit, additional evaluations when the Department determines that the medical history for the request is questionable or when there is not sufficient information to support the requirements for authorization.

004.01(B)(i)(2)PRIOR AUTHORIZATION APPROVAL/DENIAL PROCESS. The prior authorization request review and determination must be completed by one or all of the following Department representatives:

(a) Medical Director;

(b) Designated Department Program Specialists; and

(c) Medicaid Medical Consultants or Contractors for certain specialties.

004.01(B)(i)(3)NOTIFICATION PROCESS. Upon determination of approval or denial, the Department provides a written response to the following, as applicable, and depending on the source of the request:

(a) Physician(s) submitting or contributing to the request;

(b) Caseworker; and

(c) Medical Review Organization when appropriate.

004.01(B)(ii)VERBAL AUTHORIZATION PROCEDURES. The Department may issue a verbal authorization when circumstances are of an emergency nature, or urgent to the extent that a delay would place the client at risk of not receiving medical care. When a verbal authorization is granted, a written request or electronic request using the standard electronic Health Care Services Review - Request for Review and Response transaction must be submitted within 14 days of the verbal authorization. A written or electronic response from the Department will be issued upon completion of the review.

004.01(B)(iii)BILLING AND PAYMENT REQUIREMENTS. Claims submitted to the Department for services requiring prior authorization will not be paid without written or electronic approval. A copy of the approval letter or notification of authorization issued by the Department must be submitted with all claims related to the procedure or service authorized.

004.02SPECIFIC REQUIREMENTS.

004.02(A)SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID. Certain Nebraska Medicaid clients are required to participate in the Nebraska Medicaid Managed Care Program (Managed Care). Managed Care plans are required to provide, at a minimum, coverage of services as described in this chapter. Services provided to clients enrolled in a managed care plan are not billed to the Department. The provider must provide services only under arrangement with the managed care organization (MCO). The prior authorization requirements, payment limitations, and billing instructions outlined in this chapter do not apply to services provided to clients enrolled in a managed care plan with the following exceptions:

(i) Medical Transplants: Transplants continue to require prior authorization by the Department and are reimbursed on a fee-for-service basis, outside the managed care organization's (MCO) capitation payment;

(ii) Abortions: Abortions require prior authorization by the Department and are included in the capitation fee for the managed care organization (MCO); and

(iii) Family Planning Services: The client must be able to obtain family planning services upon request and from any appropriate provider who is enrolled in Nebraska Medicaid. Family planning services are reimbursed by the managed care organization (MCO), regardless of whether the service is provided by a primary care provider (PCP) enrolled with the managed care organization (MCO) or a family planning provider outside the managed care organization (MCO).

004.02(B)PRIOR AUTHORIZATION FOR TRANSPLANT SERVICES. The Department requires prior authorization of all transplant services. Physicians must request prior authorization before performing any transplant service or related donor service.

004.02(B)(i) Prior authorization requests must include at a minimum:

(1) The patient's name, Medicaid ID, and date of birth;

(2) Diagnosis, pertinent past medical history and treatment, prognosis with and without the transplant, and the procedure(s) for which the authorization is requested;

(3) Name of the hospital, city, and state where the service(s) will be performed, including the National Provider Identification number of the provider. All providers must be enrolled with Medicaid before services are performed. Out-of-state services are covered in accordance with 471 NAC 1;

(4) Name of the physician(s) who will perform the surgery if other than the physician requesting authorization; and

(5) In addition to the above information, a physician specializing in the specific transplantation must also supply the following:

(a) The screening criteria used in determining that a patient is an appropriate candidate for the requested transplant;

(b) The results of that screening for this patient (i.e., the patient is eligible to be placed on a "waiting list" for solid organ transplantation in which the only remaining criteria is organ availability); and

(c) A written statement by the physician:

(i) Recommending the transplant;

(ii) Certifying and explaining why the transplant is medically necessary as the only clinical, practical, and viable alternative to prolong the client's life in a meaningful, qualitative way and at a reasonable level of functioning; and

(iii) Psycho-social evaluation for solid organ transplants. Exception: For heart and liver transplants, a second physician specializing in the specific transplant must also supply a second written statement meeting the above criteria.

004.02(C)PRIOR AUTHORIZATION FOR GASTRIC BYPASS SURGERY. Prior authorization request must include, but is not limited to, documentation of:

(i) Medical diagnoses;

(ii) Body mass index 35 or greater with one of the following co-morbidities:

(1) Diabetes Mellitus (include recent lab results and current medications);

(2) Hypertension (include current medications, including antihypertensive and blood pressure readings);

(3) Coronary Artery Disease, Congestive Heart Failure, or dyslipidemia (include recent lab results and current medications);

(4) Obstructive sleep apnea (include sleep study results and treatment);

(5) Gastroesophageal Reflux Disease (include test results and current medications being used to manage the symptoms);

(6) Osteoarthritis (include information about the client's ability to ambulate, assistive devices used and any medications being used to manage symptoms);

(7) Pseudo tumor cerebri (include diagnostic reports/imaging); or

(8) Cardiac and pulmonary evaluations if existing cardio-pulmonary comorbidities (provide all related consults).

(iii) Dietary consultation, including documentation showing completion of a supervised diet program for six months or more, and a determination that the patient is motivated to comply with dietary changes;

(iv) Psychiatry or psychology consultation that includes:

(1) Evaluation to determine readiness for surgery and lifestyle change; and

(2) No behavior health disorder by history and physical exam:

(a) Exam includes no severe psychosis or personal disorder; and

(b) Mood or anxiety disorder excluded and treatment (if treated, include treatment medications or modalities).

(v) Drug or alcohol screen:

(1) No drugs or alcohol by history, or alcohol and drug free for a period of one year or greater; and

(2) No history of smoking, or smoking cessation has been attempted.

(vi) Patients understanding of surgical risk, post procedure compliance and follow-up.

004.03COVERED INPATIENT SERVICES.

004.03(A)BED AND BOARD. The Department pays the same amount for inpatient services whether the client has a private room, a semiprivate room, or ward accommodations.

004.03(B)PASSES OR LEAVES OF ABSENCE. The day on which a client begins a pass or leave of absence may be treated as a day of discharge. Therapeutic passes will be evaluated for medical necessity and are subject to medical review or the Department's utilization review (UR) activities. The hospital is not paid for therapeutic passes or leave days.

004.03(C)NURSING SERVICES. Nursing and other related services and use of hospital facilities for the care and treatment of inpatients are included in the hospital's payment for inpatient services.

004.03(D)SERVICES OF INTERNS AND RESIDENTS-IN-TRAINING. The Department covers the reasonable cost of the services of interns or residents-in-training under a teaching program approved by the Council on Medical Education of the American Medical Association or, in the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association.

004.03(D)(i)APPROVED PROGRAMS FOR PODIATRIC INTERNS AND RESIDENTS-IN-TRAINING. The services of interns and residents-in-training in the field of podiatry under a teaching program approved by the Council on Podiatry Education of the American Podiatry Association are covered under Nebraska Medicaid on the same basis as the services of other interns and residents-in-training in approved teaching programs.

004.03(D)(ii)DENTAL INTERNS AND RESIDENTS-IN-TRAINING. For services of interns or residents-in-training in the field of dentistry in a hospital or osteopathic hospital, the teaching program must be approved by the Council of Dental Education of the American Dental Association.

004.03(E)OUTPATIENT/EMERGENCY SERVICES. When a client receives hospital outpatient or emergency room services and is thereafter admitted as an inpatient of the same hospital before midnight of the same day, the hospital outpatient or emergency room services are covered by the Department as inpatient services. Hospital outpatient services furnished in the outpatient or emergency room to a patient classified as "dead on arrival" are covered through pronouncement of death, providing the hospital considers these patients as outpatients for recordkeeping purposes and follows its usual outpatient billing practices for services to all patients. This coverage does not apply if the patient was pronounced dead before arrival at the hospital.

004.03(F)ANCILLARY SERVICES. Payment for the ancillary services described in this section is included in the payment for inpatient services. Outpatient services must be claimed using the appropriate national standard code sets.

004.03(G)BLOOD ADMINISTRATION. For clients who are receiving both Medicare and Medicaid benefits, the Department covers the first three pints of blood. Autologous blood donation processing costs are not covered for reimbursement by the Department. The Department covers any blood administration not covered by Medicare or other third-party insurance if it is medically necessary. Hospitals must distinguish between blood and blood processing costs under the following rules:

(i) Blood Costs: A hospital's blood costs will consist of amounts it spends to procure blood, including:

(1) The cost of activities as soliciting and paying donors and drawing blood for its own blood bank; and

(2) When a hospital purchases blood from an outside blood source an amount equal to the amount of credit which the outside blood source customarily gives the hospital if the blood is replaced.

(ii) Blood Processing: A hospital's blood processing costs consist of amounts spent to process and administer blood after it has been procured, including:

(1) The cost of such activities as storing, typing, cross-matching, and transfusing blood;

(2) The cost of spoiled or defective blood. This cost does not include blood that is spoiled or defective as a result of general storage expiration; and

(3) The portion of the outside blood source's blood fee which remains after credit is given for replacement.

004.03(H)PERSONAL CARE ITEMS. The Department covers personal care items, such as lotion, toothpaste, and admit kits, when they are necessary for the care of a client during inpatient or outpatient services.

004.04DRUGS.

004.04(A)INPATIENT DRUGS. The Department covers drugs for use in the hospital which are ordinarily provided by the hospital for the care and treatment of inpatients. Payment for inpatient drugs is included in the hospital's payment for inpatient services.

004.04(B)HOSPITAL OUTPATIENT OR EMERGENCY ROOM DRUGS. The Department covers drugs utilized in the actual treatment as part of the outpatient or emergency room service. The hospital must bill drugs used in the outpatient or emergency room service by National Drug Code (NDC) on Form CMS-1450 or the standard electronic Health Care Claim: Institutional transaction (ASC X12N 837). Providers must also report the quantity and unit of measure of the National Drug Code (NDC). Include the correct National Drug Code (NDC) information on all claims, including Medicare and other third party claims.

004.05MEDICAL SUPPLIES AND EQUIPMENT.

004.05(A)INPATIENT SUPPLIES AND EQUIPMENT. The Department covers supplies and equipment provided to inpatients for use during the inpatient stay. These are included in the hospital's payment for inpatient services. Certain items used during the client's inpatient stay are included in the hospital's payment for inpatient services even though they leave the hospital with the client. This includes items used in the actual treatment of the patient which are permanently or temporarily inserted in or attached to the patient's body.

004.05(B)HOSPITAL OUTPATIENT AND EMERGENCY ROOM SUPPLIES AND EQUIPMENT. The Department covers medically necessary supplies and equipment used for outpatient and emergency room services. This includes items used in the actual treatment of the patient as well as items necessary to facilitate the patient's discharge.

004.05(C)TAKE-HOME SUPPLIES AND EQUIPMENT. The Department covers the following supplies and equipment:

(1) Up to a 10-day supply of take-home supplies following an inpatient or outpatient service. Durable medical equipment must be billed by appropriate provider with the exception of rental apnea monitors and home phototherapy units.

004.05(C)(i)INFANT APNEA MONITORS. The Department covers rental of home infant apnea monitors for infants with medical conditions that require monitoring due to a specific medical diagnosis only if prescribed by and used under the supervision of a physician. Proper infant evaluation by the physician and parent or caregiver training must occur before placement of infant apnea monitor. Payment for hospital apnea monitoring services provided to an inpatient is included in the hospital payment for inpatient services.

004.05(C)(ii)PHOTOTHERAPY SERVICES. The Department covers phototherapy equipment on a rental basis for infants that meet the following criteria:

(a) Neonatal hyperbilirubinemia is the infant's sole clinical problem;

(b) The infant is greater than or equal to 37 weeks gestational age and birth weight greater than 2,270 gm (5 lbs.);

(c) The infant is greater than 48 hours of age;

(d) Bilirubin level at initiation of phototherapy (greater than 48 hours of age) is 1418 mgs per deciliter. Home phototherapy is not covered if the bilirubin level is less than 12 mgs at 72 hours of age or older; and

(e) Direct bilirubin level is less than 2 mgs per deciliter.

004.06LABORATORY AND PATHOLOGY.

004.06(A)PROFESSIONAL COMPONENT. The Department covers as a physician's service the professional component of laboratory services provided by a physician to an individual patient in accordance with the provisions of 471 NAC 18. The professional component must be billed on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837).

004.06(B)CLINICAL LAB SERVICES. Clinical laboratory services are considered technical components and must be billed as such. The Department covers the technical component of clinical laboratory services provided to hospital inpatients, outpatients, and non-patients performed by non-physicians manually or using automated laboratory equipment. Payment is made to the hospital as follows:

(1) Inpatient Services: Payment is included in the hospital's payment for inpatient services. The hospital may include these costs on its cost report to be considered in calculating the hospital's payment rate.

(2) Outpatient Services: Payment is made at the fee schedule determined by Centers for Medicare and Medicaid Services. Outpatient clinical laboratory services must be itemized on the appropriate claim form or electronic format using the appropriate healthcare common procedure coding system procedure codes.

(3) Non-Patient Services: Payment is made at the fee schedule determined by Centers for Medicare and Medicaid Services.

004.06(B)(i)LEASED DEPARTMENTS. Leased department status has no bearing on billing or payment for clinical lab services. The hospital must claim all clinical lab services, whether performed in a leased or non-leased department. Payment for the total service (professional and technical component) is made to the hospital. The Department does not make separate payment for the professional component for clinical lab services.

004.06(C)ANATOMICAL PATHOLOGY SERVICES. Services which ordinarily require a physician's interpretation. If these services are provided to hospital inpatients or outpatients, the professional and technical components must be separately identified for billing and payment. There is no separate payment made to the pathologist for routine clinical lab services. To be paid, the pathologist must negotiate with the hospital to arrange a salary or compensation agreement.

004.06(C)(i)BILLING AND PAYMENT FOR HOSPITAL INPATIENT ANATOMICAL PATHOLOGY SERVICES. Payment for the technical component of anatomical pathology is included in the hospital's payment for inpatient services which is claimed on the appropriate claim form or electronic format as an ancillary service. The hospital may include these costs on its cost report to be considered in calculating the hospital's payment rate. The pathologist must claim the professional component of anatomical pathology on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837) using the appropriate healthcare common procedure system procedure code and a "26" modifier. This service is paid according to the Nebraska Medicaid Practitioner Fee Schedule.

004.06(C)(i)(1)EXCEPTION. If an anatomical pathology specimen is obtained from a hospital inpatient but is referred to an independent laboratory or the pathologist of a second hospital's laboratory, the independent lab or the pathologist of the second hospital's laboratory to which the specimen has been referred may claim payment for the total service on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837). Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule.

004.06(C)(ii)BILLING AND PAYMENT FOR HOSPITAL OUTPATIENT ANATOMICAL PATHOLOGY SERVICES. The hospital must bill the technical component of outpatient anatomical pathology services in a summary bill format using the appropriate revenue code on the appropriate claim form or electronic format. The pathologist must claim the professional component on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837) using the appropriate healthcare common procedure system procedure code and a "26" modifier. Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule.

004.06(C)(ii)(1)EXCEPTION. If an anatomical pathology specimen is obtained from a hospital outpatient and is referred to an independent lab or the pathologist of a second hospital's laboratory, the independent lab or the pathologist of a second hospital's laboratory to which the specimen was referred may claim payment for the total service on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837). Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule.

004.06(C)(iii)BILLING AND PAYMENT FOR NON-PATIENT ANATOMICAL PATHOLOGY SERVICES. For specimens from non-patients referred to the hospital, the hospital must bill the total service on the appropriate claim form or electronic format using the appropriate revenue code.

004.06(C)(iv)LEASED DEPARTMENTS. If the pathology department is leased and an anatomical pathology service is provided to a hospital non-patient, the pathologist must claim the total service (professional and technical components) on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837). Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule. Leased department status has no bearing on billing for or payment for hospital inpatient or outpatient anatomical pathology services.

004.06(D)ADJUSTMENT BASED ON LEGISLATIVE APPROPRIATIONS. The starting point for the payment amounts must be adjusted by a percentage. This percentage will be determined by the Department as required by the available funds appropriated by the Nebraska Legislature.

004.07HOSPITAL DIAGNOSTIC AND THERAPEUTIC SERVICES. Hospital diagnostic and therapeutic services are procedures performed to determine the nature and severity of an illness or injury, or procedures used to treat disease or disorders. Hospital diagnostic and therapeutic services include both hospital inpatient and outpatient services. Hospital diagnostic and therapeutic services are comprised of two distinct elements: the professional component and the technical component.

004.07(A)PROFESSIONAL COMPONENT. See 471 NAC 18.

004.07(B)TECHNICAL COMPONENT. The technical component of hospital diagnostic and therapeutic services is comprised of two distinct elements:

(1) Physicians' professional services not directly related to the medical care of the individual patient; and

(2) Hospital services.

004.07(B)(i) Payment for the technical component of inpatient services is included in the hospital's payment for inpatient services whether provided directly or under arrangement with an outside provider. The hospital is responsible for payment of all services provided to an inpatient under arrangement by an outside provider, except ambulance services, to the outside provider (for inpatient services) if the service is provided under arrangement.

004.07(B)(ii) The technical component of outpatient and non-patient services must be claimed by the provider actually providing the service. The Department's payment for the technical component includes payment for all non-physician services required to provide the procedure; including, but not limited to stat fees, specimen handling, call back, room charges, etc.

004.07(D)NON-PHYSICIAN SERVICES AND ITEMS. All non-physician services, drugs, medical supplies, and items, provided to hospital inpatients or outpatients must be provided directly by the hospital or under arrangements. If the services or items are provided under arrangements, the hospital is responsible for payment to the non-physician provider or supplier. The Department prohibits the "unbundling" of costs by hospitals for non-physician services or supplies provided to hospital patients, including ancillary services provided by another hospital.

004.08RADIOLOGY. The Department covers medically necessary radiological services provided to inpatients and outpatients. The Department covers only those services which are directly related to the patient's diagnosis and the provider must indicate the diagnosis which reflects the condition for which the service is performed on the claim from, and if necessary, include a notation on the claim which documents the need. A radiological laboratory is not considered an independent laboratory under Medicaid. All radiology services have a technical component and a professional component (physician interpretation). The professional and technical component of hospital services must be separately identified for billing and payment.

004.08(A) PROFESSIONAL COMPONENT. The professional component of radiology services provided by a physician to an individual patient is covered in accordance with 471 NAC 10.

004.08(B)TECHNICAL COMPONENT. The Department covers the technical component of hospital radiology services, such as administrative or supervisory services or services needed to produce the x-ray films or other items that are interpreted by the radiologist.

004.08(C)COMPUTERIZED TOMOGRAPHY (CT) SCANS. The Department covers diagnostic examinations of the head and of certain other parts of the body performed by computerized tomography (CT) scanners when:

(i) Medical and scientific literature and opinion support the use of a scan for the condition;

(ii) The scan is reasonable and necessary for the individual patient; and

(iii) The scan is performed on a model of computerized tomography (CT) equipment that meets Medicare's criteria for coverage.

004.08(D)MAMMOGRAMS. The Department covers diagnostic and screening mammograms. Mammography services are covered only for providers who have met Medicare certification criteria for mammography services.

(i) Screening mammography: Screening mammograms are a preventive radiology procedure performed for early detection of breast cancer. The Department covers one screening mammogram annually according to the periodicity schedule and guidelines of the American Cancer Society.

(ii) Diagnostic mammography: Diagnostic mammograms are covered based on the medical necessity of the service.

004.08(E)PORTABLE X-RAY SERVICES. The Department covers diagnostic x-ray services provided by a certified portable x-ray provider when provided in a place of residence used as the patient's home and in nonparticipating institutions. These services must be performed under the general supervision of a physician and certain conditions relating to health and safety must be met.

004.08(E)(i)COVERED PORTABLE X-RAY SERVICES. The Department covers the following portable x-ray services:

(1) Skeletal films involving arms and legs, pelvis, vertebral column, and skull;

(2) Chest films which do not involve the use of contrast media; and

(3) Abdominal films which do not involve the use of contrast media.

004.08(E)(ii)SPECIAL NEEDS FACILITIES. The Department covers diagnostic portable x-ray services when provided in participating special need facilities, under circumstances in which they cannot be covered as special need facilities services. If portable x-ray services are provided in a participating hospital under arrangement, the hospital must bill the Department for the service.

004.08(E)(iii)ELECTROCARDIOGRAMS. The taking of an electrocardiogram tracing by an approved supplier of portable x-ray services can be covered as an "other diagnostic test." The health and safety standards in 471 NAC 10 must be met.

004.08(E)(iv)CERTIFIED PROVIDERS. Providers of portable x-ray services must be certified by the Centers for Medicare and Medicaid Services Regional Office. The Centers for Medicare and Medicaid Services Regional Office updates certification information and sends the information to the Department according to the federal time frame which is currently in effect for portable x-ray providers.

004.08(E)(iv)(1)NEBRASKA PORTABLE X-RAY PROVIDER. The provider must submit Form CMS-1539: Medicare/Medicaid Certification and Transmittal.

004.08(E)(iv)(2)OUT-OF-STATE PORTABLE X-RAY PROVIDER. The Department approves or denies enrollment based on verification of certification information received from the Centers for Medicare and Medicaid Services Regional Office.

004.08(E)(v)APPLICABILITY OF HEALTH AND SAFETY STANDARDS. The health and safety standards apply to all providers of portable x-ray services, except physicians who provide immediate personal supervision during the administration of diagnostic x-ray services. Payment is made only for services of approved providers who have been found to meet the standards.

004.08(E)(v)(1) When the services of a provider of portable x-ray services no longer meet the conditions of coverage, physicians responsible for supervising the portable x-ray services and having an interest in the x-ray provider's certification status must be notified. The notification action regarding suppliers of portable x-ray equipment is the same as required for decertification of independent laboratories, and the same procedures are followed.

004.08(F)RADIOLOGY FOR ANNUAL PHYSICAL EXAMS FOR CLIENTS RESIDING IN NURSING FACILITIES AND INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). The Department requires that all long term care facility residents have an annual physical examination. The physician, based on their authority to prescribe continued treatment, determines the extent of the examination for Nebraska Medicaid clients based on medical necessity.

004.08(G)BILLING AND PAYMENT FOR RADIOLOGY SERVICES.

004.08(G)(i)BILLING AND PAYMENT FOR HOSPITAL INPATIENT RADIOLOGY SERVICES. Payment for the technical component of inpatient radiology services is included in the hospital's payment for inpatient services. These costs may be included on the hospital's cost report to be considered in calculating the hospital's payment rate. Physicians must claim the professional component of inpatient radiology services on Form CMS-1500 or the standard electronic Healthcare Common Procedure Coding System Claim: Professional transaction (ASC X12N 837) using the appropriate healthcare procedure code with a "26" modifier. Payment for the professional component is made according to the Nebraska Medicaid Practitioner Fee Schedule.

004.08(G)(ii)BILLING AND PAYMENT FOR HOSPITAL OUTPATIENT RADIOLOGY SERVICES. The hospital must claim the technical component of outpatient radiology services on the appropriate claim form or electronic format. Payment is made according to 471 NAC 10. The physician must claim the professional component on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837) using the appropriate Healthcare Common Procedure Coding System procedure code with a "26" modifier. Payment for the professional component is made according to the Nebraska Medicaid Practitioner Fee Schedule.

004.08(G)(iii)BILLING AND PAYMENT FOR NON-PATIENT RADIOLOGY SERVICES. A non-patient is an individual receiving services who is neither an inpatient nor an outpatient. If a radiology procedure is performed for a non-patient, the hospital must claim the total component on the appropriate claim form or electronic format.

004.08(G)(iv)LEASED DEPARTMENTS. If the radiology department is leased and the service is provided to a non-patient, the radiologist must claim the total service -both technical and professional components - on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837). Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule.

004.09OUTPATIENT DIAGNOSTIC SERVICES PROVIDED BY ARRANGEMENT. The Department covers medically necessary diagnostic services provided to an outpatient by arrangement.

004.09(A)SPECIMEN COLLECTION FEES. Separate charges made by laboratories for drawing or collecting specimens are allowable whether or not the specimens are referred to another hospital or laboratory for testing. This fee will be paid to the provider who extracted the specimen from the patient. Only one collection fee is allowed for each type of specimen for each patient encounter, regardless of the number of specimens drawn. When a series of specimens is required to complete a single test, the series is treated as a single encounter. A specimen collection fee is allowed for activities such as drawing a blood sample through venipuncture or collecting a urine sample by catheterization.

004.09(A)(i) A specimen collection fee is allowed when it is medically necessary for a laboratory technician to draw a specimen from a patient who resides in a nursing facility or who is homebound. The technician must personally draw the specimen. A specimen collection fee is not allowed for a visiting technician when a patient in a facility is not confined to the facility or when the facility has personnel on duty qualified to perform the specimen collection.

004.09(A)(ii) The fees allowed for a visiting technician cover the travel expenses of the technician, as well as the specimen drawing service, and the material and supplies used. Exceptions to this rule may be made when it is clear that the payment is inequitable in light of the distances the technician must travel to perform the test for nursing home or homebound patients in rural areas.

004.09(A)(iii) A specimen collection fee is not allowed for samples where the cost of collecting the specimen is minimal, such as a throat culture, a routine capillary puncture, or a pap smear.

004.10AMBULANCE SERVICES. A hospital-based ambulance service is an ambulance service owned and operated by a hospital. Providers of ambulance services must meet the licensure and certification requirements of the Nebraska Department of Health, Division of Public Health, Regulation and Licensure Unit. Providers of hospital-based ambulance services must comply with all applicable requirements. In addition to the medical necessity requirements outlined in 471 NAC 10, hospital-based ambulance service must comply with 471 NAC 4. In the event that the requirements in 471 NAC 4 conflict with requirements outlined in 471 NAC 10, the individual requirements in this chapter will govern.

004.10(A)BILLING FOR HOSPITAL-BASED AMBULANCE SERVICES. Hospital-based ambulance services provided to an inpatient or an outpatient must be claimed on the appropriate claim format or electronic format as a hospital outpatient service by the hospital-based ambulance provider. Hospital-based ambulance services are reimbursed as a hospital outpatient service. Hospital-based ambulance costs are not included in the calculations for hospital inpatient rates.

004.10(B)GROUND AMBULANCE SERVICES.

004.10(B)(i)BASIC LIFE SUPPORT (BLS) AMBULANCE. A basic life support (BLS) ambulance provides transportation plus the equipment and staff needed for basic services such as control of bleeding, splinting fractures, treatment for shock, delivery of babies, cardio-pulmonary resuscitation (CPR), defibrillation, etc.

004.10(B)(ii)ADVANCED LIFE SUPPORT (ALS) SERVICES. An advanced life support (ALS) ambulance provides transportation and has complex specialized lifesustaining equipment and, ordinarily, equipment for radio-telephone contact with a physician or hospital. An advanced life support (ALS) ambulance is appropriately equipped and staffed by personnel trained and authorized to provide specialized services such as administering IVs (intravenous therapy), establishing and maintaining a patient's airway, defibrillating the heart, relieving pneumothorax conditions, and performing other advanced life support procedures or services such as cardiac (EKG) monitoring.

004.10(B)(iii)BASE RATES. Ground ambulance base rates include all services, equipment and other costs, including: vehicle operating expenses, services of two attendants and other personnel, overhead charges, reusable and disposable items and supplies, oxygen, pharmaceuticals, unloaded and in-town mileage, and usual waiting or standby time.

004.10(C)MILEAGE. Loaded mileage- miles traveled while the client is present in the ambulance vehicle - is covered for out-of-town ambulance transports. Out-of-town transports are defined as trips in which the final destination of the client is outside the limits of the town in which the trip originated. "Unloaded" mileage is included in the payment for the base rate.

004.10(D)THIRD ATTENDANT. A third attendant is covered only if the circumstances of the transport requires three attendants. The circumstances which required the third attendant must be documented on or with the claim when billing the Department. Payment for a third attendant cannot be made when the third attendant is:

(i) Needed because a crew member is not qualified to provide a service; or

(ii) Staff provided by the hospital to accompany a client during transport.

004.10(E)WAITING OR STANDBY TIME. Waiting or standby time is separately reimbursed only when unusual circumstances exist. The unusual circumstances including why the ambulance waited and where the wait took place must be documented on or with the claim when billing the Department. When waiting time is covered, the first one-half hour is not reimbursed. Payment for waiting time under normal circumstances is included in the payment for the base rate.

004.10(F)AIR AMBULANCE. The Department covers medically necessary air ambulance services only when transportation by ground ambulance is contraindicated and:

(1) Great distances or other obstacles are involved in getting the client to the destination;

(2) Immediate and rapid admission is essential; or

(3) The point of pickup is inaccessible by land vehicle.

004.10(F)(i) When billing the Department, the provider must bill air ambulance services as a single charge which includes base rate and mileage. The number of "loaded" miles must be included on the claim. If a determination is made that ambulance transport is medically necessary, but ground ambulance would have been appropriate, payment for the air ambulance service is limited to the amount allowable for ground transport.

004.10(G)LIMITATIONS AND REQUIREMENTS FOR CERTAIN AMBULANCE SERVICES.

004.10(G)(i)EMERGENCY AND NON-EMERGENCY TRANSPORTS. Emergency transports are defined as services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in:

(a) Placing the client's health in serious jeopardy;

(b) Serious impairment to bodily functions; or

(c) Serious dysfunction of any bodily organ or part.

004.10(G)(i)(1) Any ambulance transport that does not meet the definition of an emergency transport must be billed as a non-emergency transport. This includes all scheduled runs regardless of origin and destination and transports to nursing facilities or to the client's residence.

004.10(G)(ii)TRANSPORTS TO THE FACILITY WHICH MEETS THE NEEDS OF THE CLIENT. Ambulance services are covered to enable the client to obtain medical care in a facility or from a physician or practitioner that most appropriately meets the needs of the client, including:

(1) Support from the client's community or family; or

(2) Care from the client's own physician, practitioner, or a qualified physician or practitioner or specialist.

004.10(G)(iii) TRANSPORTS TO A PHYSICIAN/PRACTITIONER'S OFFICE, CLINIC OR THERAPY CENTER. Emergency ambulance transports to a physician or practitioner's office, clinic or therapy center are covered. Non-emergency ambulance transports to a physician or practitioner's office, clinic or therapy center are covered when:

(1) The client is bed confined before, during, and after transport; and

(2) The services cannot or cannot reasonably be expected to be provided at the client's residence including a nursing facility or intermediate care facilities for individuals with developmental disabilities (ICF/DD).

004.10(G)(iv)ROUND TRIP TRANSPORTS FOR HOSPITAL INPATIENTS. Ambulance services provided to a client receiving hospital inpatient services, where the client is transported to another facility for services and the client is returned to the originating hospital for continuation of inpatient care, are not included in the payment to the hospital for inpatient services and must be billed by the hospital-based ambulance provider.

004.10(G)(v)COMBINED ADVANCED LIFE SUPPORT (ALS)/ BASIC LIFE SUPPORT (BLS) TRANSPORTS. When a client is transferred from a basic life support (BLS) vehicle to an advanced life support (ALS) ambulance, the advanced life support (ALS) service may be billed, however only one ambulance provider may submit the claim for the service.

004.10(G)(v)(1) When the placement of advanced life support (ALS) personnel and equipment on board a basic life support (BLS) vehicle qualifies the basic life support (BLS) vehicle as an advanced life support (ALS) ambulance, the advanced life support (ALS) service may be billed.

004.10(G)(vi)TRANSPORT OF MORE THAN ONE CLIENT. When more than one client is transported during a single trip, a base rate is covered for each client transported. The number of loaded miles and mileage charges must be prorated among the number of clients being billed. A notation that the mileage is prorated and why must be on or with the claim when billing the Department.

004.10(G)(vii)TRANSPORT OF MEDICAL TEAMS. Transport of a medical team or other medical professionals to meet a client is not separately reimbursed. If the transport of the medical team results in an ambulance transport of the client, the services are included in the base rate of the client's transport.

004.10(G)(viii)TRANSPORT OF DECEASED CLIENTS. Ambulance services are covered if the client is pronounced dead while en route to or upon arrival at the hospital. Ambulance services are not covered if a client is pronounced dead before the client is transported.

004.11PRE-ADMISSION TESTING. The Department covers pre-admission testing and diagnostic services rendered up to three days before the day of admission, as an ancillary.

004.11(A) The Department does not cover pre-admission testing performed in a physician's office or as an outpatient which is performed solely to meet hospital preadmission requirements.

004.12HOSPITAL ADMISSION DIAGNOSTIC PROCEDURES. In addition to meeting medical necessity requirements, the major factors which are considered to determine that a diagnostic procedure performed as part of the admitting procedure to a hospital is reasonable and medically necessary are:

(A) The test is specifically ordered by the admitting physician, or a hospital staff physician responsible for the patient when there is no admitting physician (i.e., the test is not provided on the standing orders of a physician for all their patients);

(B) The test is medically necessary for the diagnosis or treatment of the individual patient's condition; and

(C) The test does not unnecessarily duplicate:

(i) The same test performed on an outpatient basis before admission; or,

(ii) The same test performed in connection with a separate, but recent, hospital admission.

004.13THERAPEUTIC SERVICES. Therapeutic services, including physical, respiratory, occupational, speech, or psychological therapies which a hospital provides to an inpatient or outpatient are those services which are incidental to the services of the physicians in the treatment of patients. Covered therapeutic services to hospital inpatients or outpatients include the services of therapists and equipment necessary for therapeutic services.

004.13(A)COVERED SERVICES - PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH PATHOLOGY SERVICES. The Department covers physical therapy, occupational therapy, speech pathology, and audiology services in accordance with the criteria outlined in 471 NAC 17, 471 NAC 14, and 471 NAC 23 respectively.

004.13(B)RESPIRATORY THERAPY. The Department covers respiratory therapy when provided by a respiratory therapist or technician in accordance with the conditions and criteria outlined in 471 NAC 22.

004.14ANESTHESIOLOGY.

004.14(A)PROFESSIONAL COMPONENT. The Department covers the professional component of anesthesiology services provided by a physician to an individual patient in accordance with 471 NAC 18. Rural hospitals that have been exempted by their Medicare fiscal intermediary for certified registered nurse anesthetist (CRNA) billing must follow the Medicare billing requirements.

004.14(A)(i)MEDICAL DIRECTION OF FOUR OR FEWER CONCURRENT PROCEDURES. The Department covers the professional component for the physician's personal medical direction of concurrent anesthesiology services provided by qualified anesthetists, such as certified registered nurse anesthetists (CRNA), in accordance with 471 NAC 10. The professional component of personal services up to and including induction is covered as a physician's service and must be billed on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837).

004.14(B)TECHNICAL COMPONENT. If the physician leaves the immediate area of the operating suite for longer than short durations, devotes extensive time to an emergency case, or is otherwise not available to respond to the immediate needs of surgical patients, the physician's services to the surgical patient are supervisory in nature and are considered a technical component.

004.14(B)(i)MEDICAL DIRECTION OF MORE THAN FOUR CONCURRENT PROCEDURES. If the physician is involved in providing direction for more than four concurrent procedures or is performing other services while directing the concurrent procedures, the concurrent anesthesia services are covered as the technical component of the hospital services. The physician must ensure that a qualified individual performs any procedure in which the physician does not personally participate.

004.14(C)STANDBY ANESTHESIA SERVICES. A physician's standby anesthesia services are covered when the physician is physically present in the operating suite, monitoring the patient's condition, making medical judgments regarding the patient's anesthesia needs and ready to furnish anesthesia services to a specific patient who is known to be in potential need of services. The professional component must be billed on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837).

004.14(D)NURSE ANESTHETIST. The hospital may engage the services of a nurse anesthetist, either on a salary or fee-for-service basis, under arrangements which provide for billing to be made by the hospital. Reimbursement for the service when provided to an inpatient or outpatient is included in the payment rate under Nebraska Medicaid.

004.15OUTPATIENT SURGICAL PROCEDURE. When a patient with a known diagnosis enters a hospital for a specific surgical procedure or other treatment that is expected to keep the individual in the hospital for less than 24 hours, and this expectation is realized, the patient will be considered an outpatient regardless of the hour of admission; whether or not the patient used a bed; and whether or not the patient remained in the hospital past midnight. If the patient receives 24 or more hours of care, the patient is considered an inpatient regardless of the hour of admission or whether the patient remained in the hospital past midnight or the census-taking hour.

004.16OUTPATIENT OBSERVATION SERVICES. The Department covers a maximum of 48 hours of outpatient observation. After 48 hours, the patient must either be admitted as an inpatient, by written order, or discharged.

004.17HOSPITAL DENTAL SERVICES. When dental treatment is necessary as a hospital inpatient or outpatient service, these services must be provided, billed and reimbursed in accordance with the provisions of 471 NAC 6.

004.18OTHER ANCILLARY SERVICES.

004.18(A)EMERGENCY ROOM PHYSICIANS' SERVICES. The hospital must bill the Department for emergency room physicians' services on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837) using the physician's provider number.

004.18(B)DIALYSIS SERVICES. The Department covers both hemodialysis and peritoneal dialysis as acceptable modes for treatment of end stage renal disease.

004.18(B)(i)INPATIENT DIALYSIS SERVICES. Dialysis services provided to an individual who is an inpatient are considered to be inpatient services.

004.18(B)(ii)OUTPATIENT DIALYSIS SERVICES. Outpatient dialysis services are those dialysis services provided to an individual who is an outpatient. Outpatient dialysis services must be provided by a Medicare certified renal dialysis facility.

004.18(B)(iii)PAYMENT FOR OUTPATIENT DIALYSIS SERVICES. Outpatient dialysis services are reimbursed at the provider's current Medicare composite rate for the services provided. Payment excludes the cost of physician services.

471 Neb. Admin. Code, ch. 10, § 004

Amended effective 11/9/2020

Amended effective 6/6/2022