Section 471-33-005 - BILLING AND PAYMENT FOR HEALTH CHECK SERVICES005.01BILLING.005.01(A)GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that individual billing requirements in 471 NAG 3 conflict with billing requirements outlined in this 471 NAC 33, the individual billing requirements in 471 NAC 33 will govern.005.01(B)SPECIFIC BILLING REQUIREMENTS. Providers must bill the Department using Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837) for HEALTH CHECK exams, HEALTH CHECK-associated services, and other comparable exams. The physician or the physician's authorized agent must submit the physician's usual and customary charge for each procedure code listed on or in the claim. 005.01(B)(i)PROCEDURE CODES. Physicians must use Healthcare Common Procedure Coding System (HCPCS) procedure codes when submitting claims or encounter data to the Department. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes used by Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule.005.01(B)(ii)VACCINE FOR CHILDREN PROGRAM (VFC) PROGRAM. When a physician uses federal-purchased vaccine for immunizations, the physician must bill the Department only for the administration. The physician must use the modifier "SL" with the vaccine code when billing for the administration. Billed charges for the administration of Vaccine for Children Program (VFC) vaccines cannot exceed the state maximum as determined by the federal Vaccine for Children Program (VFC) program. Contact the Nebraska Vaccine for Children Program (VFC) program with questions regarding the Nebraska maximum.005.02PAYMENT.005.02(A)GENERAL PAYMENT REQUIREMENTS. The Department will reimburse the Provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. in the event that individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this 471 NAC 33. the individual payment regulations in 471 NAC 33 will govern.005.02(B)SPECIFIC PAYMENT REQUIREMENTS. The Department pays for covered HEALTH CHECK services, except for clinical laboratory services or individuals enrolled in managed care, at the lower of: (1) The provider's submitted charge; or(2) The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule for that date of service.005.02(B)(i)VACCINE FOR CHILDREN PROGRAM (VFC) PROGRAM. The Department reimburses for the administration of Vaccine for Children Program (VFC) vaccine according to the Nebraska Medicaid Practitioner Fee Schedule.005.02(B)(ii)SPECIAL SERVICES. Payment for special services is made according to the Nebraska Medicaid Practitioner Fee Schedule unless included as part of a capitation plan. The Department may also withdraw a provider's approval by written notification to the provider if the provider no longer meets the following identified requirements.005.02(B)(iii)ENVIRONMENTAL INVESTIGATION FOR LEAD CONTAMINATION. Payment will be made under an interagency contract with local or state health departments utilizing a certified lead inspector at a negotiated rate that includes the initial environmental investigation and a follow-up visit, if needed.471 Neb. Admin. Code, ch. 33, § 005
Amended effective 2/12/2022