Section 471-29-002 - Services Provided for Clients Enrolled in the Nebraska Health Connection (NHC) Certain NMAP clients are required to participate in the Nebraska Medicaid Managed Care Program known as the Nebraska Health Connection (NHC). See 471-000-122 for a listing of the NHC plans.
002.01 Health Maintenance Organization (HMO) Plans The NHC HMO plans are required to provide, at a minimum, coverage of services as described in this Chapter. The prior authorization requirements, payment limitations, and billing instructions outlined in this Chapter do not apply to services provided to clients enrolled in an NHC HMO plan with the following exceptions:
1.Medical Transplants: As defined under 471 NAC 18-004.40, transplants continue to require prior authorization by NMAP and are reimbursed on a fee-for-service basis, outside the HMO's capitation payment;2.Abortions: As currently defined, abortions continue to require prior authorization by NMAP and are included in the capitation fee for the HMO; and3.Family Planning Services: Family planning services do not require a referral from a primary care physician (PCP). As defined in 471 NAC 18-004.26, the client must be able to obtain family planning services upon request and from a provider of choice who is enrolled in NMAP. Family planning services are reimbursed by the HMO, regardless of whether the service is provided by a PCP enrolled with the HMO or a family planning provider outside the HMO. Services provided to clients enrolled in an NHC HMO plan are not billed to NMAP. The provider shall provide services only under arrangement with the HMO.
002.02 Primary Care Case Management (PCCM) Plans All NMAP regulations apply to services provided to NHC clients enrolled in a PCCM plan. For services that require prior authorization under 471 NAC 18-004.01, the provider must obtain prior authorization from the PCCM plan under the directions for prior authorization of the PCCM plan with the following exceptions:
1.Medical Transplants: As define under 471 NAC 18-004.40, transplants are subject to prior authorization by NMAP; and2.Abortions: As currently defined, abortions require prior authorization by NMAP.29-002.02AReferral Management: When medically necessary services that cannot be provided by the PCP are needed for the client, the PCP must authorize the services to be provided by the approved provider as needed with the following exceptions: 1.Visual Care Services: All surgical procedures provided by an optometrist or ophthalmologist require approval from the PCCM plan. Providers must contact the client's PCCM primary care physician before providing surgical services. Non-surgical procedure provided by an optometrist or ophthalmologist do not require referral/approval from the PCP; however, when an optometrist or ophthalmologist diagnoses, monitors, or treats a condition, except routine refractive conditions, the practitioner shall send a written summary of the client's condition and treatment/follow-up provided, planned, or required to the client's PCP.2.Dental Services: Dentists or oral surgeons providing medically necessary services not covered under 471 NAC 6-000 must bill that service on Form CMS-1500 or electronically using the standard Health Care Claim: Professional transaction (ASC X12N 837), using HCPCS/CPT procedure codes. These services require referral/ authorization from the client's PCP. The provider must contact the PCP before providing these services. If a client requires hospitalization for dental treatment or for medical and surgical services billed on Form CMS-1500 or electronically using the standard Health Care Claim: Professional transaction (ASC X12N 837), the provider must_contact the PCP for referral/authorization.3.Family Planning Services: Family planning services do not require a referral from the PCP. As defined in 471 NAC 18-004.26, the client must be able to receive family planning services upon request and from a provider of choice who is enrolled in NMAP.002.03 Mental Health and Substance Abuse Services Mental health and substance abuse services (MH/SA) are provided by the MH/SA managed care plan for all NHC clients. This plan includes the Client Assistance Program (CAP). Clients may access five services annually with any CAP-enrolled provider without prior authorization. All other MH/SA services must be prior authorized by the Plan.
471 Neb. Admin. Code, ch. 29, § 002