Section 471-21-003 - Service Requirements21-003.01General Requirements21.003.01AMedical Necessity: Rehabilitation services must be provided in accordance with the medical necessity guidelines outlined in 471 NAC 1-002.02A.21.003.01BPrior Authorization of Medical Rehabilitation Care: Medicaid requires prior authorization of all medical inpatient rehabilitation services to determine the medical necessity, appropriateness of setting, and length of stay. Prior authorization functions, admission reviews, concurrent reviews, and retrospective prepayment reviews are conducted by the peer review organization (PRO), an entity contracted with Medicaid to perform these services. The PRO also performs reconsideration reviews of inpatient hospital denials when requested by the provider.21.003.01CServices Provided for Clients Enrolled in the Nebraska Medicaid Managed Care Program: See 471 NAC 1-002.01. 21.003.01C1Delayed Enrollment: When a client is in an acute care medical or rehabilitation facility prior to the client's enrollment in Managed Care, the effective date of enrollment is delayed until the client is discharged from the facility or transferred to a lower level of care. See 482 NAC 2-002.05D.21.003.01DHEALTH CHECK (EPSDT) Treatment Services: See 471 NAC Chapter 3321-003.02Covered ServicesMedicaid covers rehabilitation services for patients requiring a hospital level of care, and a rehabilitation program which incorporates a multidisciplinary coordinated team approach to upgrade his/her ability to function as independently as possible. A program of this scope usually includes:
i. Intensive skilled rehabilitation nursing care;iii. Occupational therapy; andiv. If needed, speech therapy;v. Nursing staff to provide general nursing services, and support the other disciplines by monitoring the patient's activities on the nursing floor to ensure that s/he participates in carrying out the activities of daily living utilizing the training received in therapy;vi. Ongoing general and, as needed, direct supervision of a physician with special training or experience in the field of rehabilitation (For coverage limitations, billing, and payment of physicians services, see 471 NAC 18-000.); and,vii. If needed, a psychologist and/or social worker to help resolve any psychological and social problems which are impeding rehabilitation. (For coverage limitations, billing, and payment of psychological services, see 471 NAC 20-000 and/or 32-000.) 21-003.02ARehabilitation Evaluation: When a client is admitted to the hospital for rehabilitation care, an assessment must be made of his/her: ii. Functional limitations;iv. Possible need for corrective surgery;v. Attitude toward rehabilitation; andvi. The existence of any social problems affecting rehabilitation. After these assessments are made, the physician, in consultation with the rehabilitation team, decides whether rehabilitation is possible; what the reasonable rehabilitation goals are; and what type of rehabilitation program is required to achieve these goals.
21-003.02A1Limitations to Coverage of the Initial Evaluation: 21-003.02A1aDuration of Evaluation: When more than 10 days are required to complete the initial evaluation, the Department will carefully review the case to ensure that the additional time was necessary. The Department may request, and the hospital shall submit, documentation showing the necessity of the additional time. Inpatient hospital care is required for this period, and covered under Medicaid if the client's condition warrants a multidisciplinary team evaluation.21.003.02A1bIdentical or Similar Admission Conditions: If, during a previous hospital stay, the client completed a program for essentially the same condition for which inpatient hospital care is now being provided, the Department covers the initial evaluation period only if: i. A change in circumstances has occurred which makes an evaluation reasonable and necessary; or,ii. The subsequent admission is to an institution utilizing advanced techniques or technology not available in the first institution.21-003.02A1cDementia or Senility: In view of the client's limited rehabilitation potential, a multidisciplinary team evaluation is not considered reasonable and necessary for a client who is demented or severely senile. 21-003.02A2Mental Confusion: Medicaid does not cover hospitalization for rehabilitation following an evaluation if mental confusion with an inability to learn is the only existing disability. Alternatively, the fact that an individual is "confused" is not a basis for concluding that a multidisciplinary team evaluation is not warranted. 21-003.02BRehabilitation Program: Medicaid covers hospitalization in cases where the rehabilitation team determines, after the initial evaluation, that a significant practical improvement can be expected in a reasonable period of time. Rehabilitation goals must be realistic and reasonable. Vocational rehabilitation is generally not considered a realistic goal for most clients receiving rehabilitation services under Medicaid. For the majority of clients, the most realistic rehabilitation goal is self-sufficiency in: 7. Sufficient improvement in the areas of self-sufficiency to allow the client to live in the community with assistance rather than in an institution. In assessing the reasonableness of the established goal or the likelihood that the rehabilitation goal can be achieved in a reasonable period of time, considerable weight must be given to the rehabilitation team's judgment, except where experience indicates that in a significant number of cases the team's judgment has proven to be unreliable. An expectation of the attainment of complete independence in the activities of daily living is not necessary, but there must be an expectation of an improvement that would be of a practical benefit to the client.
21-003.02CTeam Conferences: Rehabilitation team conferences must be held at least every 2 weeks to: 1. Assess the individual's progress or the problems impeding progress;2. Consider possible resolutions to the problems;3. Reassess the continuing validity of the rehabilitation goals established at the time of the initial evaluation;4. Reassess the need for any adjustment in these goals or in the prescribed treatment program; and5. Develop discharge plans. Team conferences may be a formal or informal, but must involve interactive discussion regarding the patient. The decisions made during conferences must be recorded in the patient's clinical record. The Department may request, and the hospital shall provide, documentation of team conferences.
21-003.02DDischarge: Medicaid covers a maximum of 3 days to discharge the client. If more than 3 days is needed to safely discharge the client, payment for additional days will be made only when adequate justification for the delayed discharge is submitted to the Department.21-003.03Non-Covered Services21-003.03APoor Candidate for Rehabilitation: When the initial evaluation results in a conclusion that the client is a poor candidate for rehabilitation care, Medicaid limits coverage of inpatient hospital care to a reasonable number of days needed to permit appropriate placement of the client. An intensive rehabilitation program under these circumstances is not considered reasonable and necessary to the treatment of the client's illness or injury.21-003.03BFurther Progress is Unlikely: Rehabilitation services are covered until further progress toward the established rehabilitation goal is unlikely, or further progress may be achieved in a less intensive setting. In making decisions as to whether further progress may be carried out in a less intensive setting, the Department considers: 1. The degree of improvement which has occurred; and2. The type of program required to achieve further improvement. When further progress is unlikely, coverage is provided through the time it is reasonable for the physician, in consultation with the rehabilitation team, to have concluded that further improvement would not occur, and effected the client's discharge. Because planning is an integral part of any rehabilitation program and must begin upon the client's admittance to the facility, an extended period of time for discharge action is not reasonable after:
1. Established goals have been reached;2. A determination has been made that further progress is unlikely; or3. Care in less intensive setting is appropriate471 Neb. Admin. Code, ch. 21, § 003