Current through September 17, 2024
006.01
PRIOR AUTHORIZATION PROCEDURES. The physician must
request prior authorization for these services in writing or the standard
electronic Health Care Services Review: Request for Review and Response
transaction (ASC X12N 278) prior to providing the service.
006.01(A)
REQUEST FOR ADDITIONAL
EVALUATIONS. The Department may request additional evaluations
when the medical history for the request is questionable or when there is not
sufficient information to support the requirements for authorization.
006.01(B)
PRIOR AUTHORIZATION
APPROVAL/DENIAL PROCESS. The prior authorization request review
and determination must be completed by one or all of the following Department
representatives:
(1) Medical
Director;
(2) Designated Department
Program Specialists; and
(3)
Medical Consultants for the Department for certain specialties.
006.01(C)
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 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 (ASC X12N 278) must be submitted within 14 days of the
verbal authorization.
006.01(D)
BILLING AND PAYMENT REQUIREMENTS. Claims submitted to
the Department for services defined as requiring prior authorization will not
be paid without written or electronic approval from the Department. 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.
006.02
HIV TESTING FOR ACQUIRED IMMUNE DEFICIENCY SYNDROME.
Payment for HIV testing is limited to medical necessity.
006.02(A)
NON-COVERED HIV
TESTING. The Department does not pay for HIV testing when there is
no history of risk as defined in 471 NAC 10. This includes, but is not limited
to, the following:
(i) Routine prenatal
screening;
(ii) Routine
pre-operative testing;
(iii)
Educational or employment requirements;
(iv) Entrance requirements for the armed
services; and
(v) Insurance
applications.
006.03
MINOR SURGICAL
PROCEDURES. Reimbursement for excision of lesions of the skin or
subcutaneous tissues includes all services and supplies necessary to provide
the service. The Department does not make additional reimbursement for suture
removal to the physician who performed the initial service or to a hospital. If
the sutures are removed by a non-hospital-based physician who is not the
physician who provided the initial service, the Department may approve separate
payment for the suture removal.
006.04
TREATMENT FOR
OBESITY. The Department will not make payment for services
provided when the sole diagnosis is obesity. While obesity is not itself
considered an illness, there are conditions which can be caused by or
aggravated by obesity. This may include but is not limited to the following:
hypothyroidism, Cushing's disease, hypothalamic lesions, cardiac diseases,
respiratory diseases, diabetes, hypertension, diseases of the skeletal system.
Treatment for obesity can be covered when the services are an integral and
necessary part of a course or treatment.
006.04(A)
INTESTINAL BY-PASS
SURGERY. The Department does not consider this procedure to be
reasonable and necessary, and does not cover the procedure.
006.04(B)
GASTRIC BY-PASS SURGERY
FOR OBESITY. Gastric by-pass surgery for patients with extreme
obesity can be covered when the surgery is:
(a) Medically appropriate for the individual;
and
(b) Performed to correct an
illness which caused the obesity or was aggravated by the obesity.
006.04(B)(i) This procedure must be performed
at a facility that is a Bariatric Surgery Center of Excellence.
006.05
COSMETIC AND RECONSTRUCTIVE SURGERY. The Department
covers cosmetic and reconstructive surgical procedures and medical services
when medically necessary for the purpose of correcting the following
conditions:
(i) Limitations in movement of a
body part caused by trauma or congenital conditions;
(ii) Disfiguring or painful scars in areas
that are visible;
(iii) Congenital
birth anomalies;
(iv)
Post-mastectomy breast reconstruction; and
(v) Other procedures determined to be
restorative or necessary to correct a medical condition.
006.05(A)
EXCEPTIONS. To determine the medical necessity of the
condition, the Department requires prior authorization for cosmetic and
reconstructive surgical procedures except for the following conditions:
(i) Cleft lip and cleft palate;
(ii) Post-mastectomy breast
reconstruction;
(iii) Congenital
hemangioma's of the face; and
(iv)
Nevus (mole) removals.
006.06
STERILIZATIONS.
006.06(A)
COVERAGE
RESTRICTIONS. Nebraska Medicaid is prohibited from paying for
sterilization of individuals:
(i) Under the
age of 21 on the date the client signs Form MMS-100; or
(ii) Legally incapable of consenting to
sterilization.
006.06(B)
COVERAGE CONDITIONS. The Department covers
sterilizations only when:
(i) The
sterilization is performed because the client receiving the service made a
voluntary request for services;
(ii) The client is advised at the outset and
before the request or receipt of their consent to the sterilization that
benefits provided by programs or projects will not be withdrawn or withheld
because of a decision not to be sterilized;
(iii) Clients whose primary language is other
than English must be provided with the required elements for informed consent
in their primary language;
(iv)
Suitable arrangements must be made to communicate the required elements of
informed consent to an individual who is blind, deaf, or otherwise
handicapped.
006.06(C)
PROCEDURE FOR OBTAINING SERVICES. Non-therapeutic
sterilizations are covered by the Department only when:
(1) Legally effective informed consent is
obtained on Form MMS-100: Consent Form from the client on whom the
sterilization is to be performed. The surgeon must submit a properly completed
and legible Form MMS-100 to the Department before payment of claims can be
considered; and
(2) The
sterilization is performed at least 30 days following the date informed consent
was given. To calculate this time period, day 1 is the first day following the
date on which the form is signed by the client. Day 31 in this period is the
first day on which the procedure could be covered by the Department. The
consent is effective for 180 days from the date Form MMS-100 is signed.
006.06(C)(i)
EXCEPTION. An individual may consent to be sterilized
at the time of a premature delivery or emergency abdominal surgery, if at least
72 hours have passed since he or she signed the informed consent for the
sterilization. For a premature delivery, the client must have signed the
informed consent at least 72 hours before the surgery is performed and at least
30 days before the expected date of delivery; the expected delivery date must
be entered on Form MMS-100.
006.06(C)(ii)
INFORMED
CONSENT. Informed consent means the voluntary, knowing assent of
the client who is to be sterilized after the individual has been given the
following information:
(a) A clear
explanation of the procedures to be followed;
(b) A description of the attendant
discomforts and risks that may follow the procedure, including an explanation
of the type and possible effects of an anesthetic to be used;
(c) A description of the benefits to be
expected;
(d) Counseling concerning
appropriate alternative methods, and the effect and impact of the proposed
sterilization including the fact that it must be considered an irreversible
procedure;
(e) An offer to answer
any questions concerning the procedures; and
(f) An instruction that the individual is
free to withhold or withdraw their consent to the sterilization at any time
before the sterilization without prejudicing their future care and without loss
of other project or program benefits to which the client might otherwise be
entitled;
(g) Advice that the
sterilization will not be performed for at least 30 days, except under the
circumstances; and
(h) The
individual to be sterilized must be permitted to have a witness of her or his
choice present when informed consent was obtained.
006.06(C)(ii)(1)
CLIENT
RESPONSIBILITY. This information is shown on Form MMS-100, which
must be completed by the client.
006.07
HYSTERECTOMIES. For payment of claims for
hysterectomies, the surgeon must submit to the Department Form MMS-101:
Informed Consent Form, properly signed and dated by the client in which the
patient states that they were informed before the surgery was performed that
this surgical procedure results in permanent sterility before claims associated
with the hysterectomy can be considered. The completed Form MMS101 must be
submitted to the Department, by the surgeon before claims for the hysterectomy
can be considered for payment. The Department covers a medically necessary
hysterectomy if the following conditions have been met:
(i) The person who secured authorization to
perform the hysterectomy has informed the individual and her representative, if
any, orally and in writing, that the hysterectomy will make the individual
permanently incapable of reproducing; and
(ii) The individual or her representative, if
any, has signed Form MMS-101 acknowledging receipt of that information.
006.07(A)
EXCEPTION. The Department does not require informed
consent if:
(1) The individual was already
sterile before the hysterectomy and the physician who performs the hysterectomy
certifies in writing that the individual was already sterile before the
hysterectomy and states the cause of the sterility.
(2) In the case of a post-menopausal woman,
the Department considers the woman to be sterile. All claims related to the
procedure must indicate that the client is postmenopausal.
(3) The individual requires a hysterectomy
because of a life-threatening emergency situation in which the physician
determines that prior acknowledgment is not possible, and the physician who
performs the hysterectomy certifies in writing that the hysterectomy was
performed under a life-threatening emergency situation in which the patient
determined prior acknowledgment was not possible. The physician must also
include certification of the emergency.
006.07(A)(i) A copy of the physician's
certification regarding the above exceptions must be submitted to the
Department before consideration for payment for claims associated with the
hysterectomy can be submitted.
006.07(B)
NON-COVERED
HYSTERECTOMIES. The Department will not cover a hysterectomy if:
(i) It was performed solely to make the woman
sterile; or
(ii) If there was more
than one purpose for the procedure, it would not have been performed except to
make the woman sterile.
006.08
ABORTIONS.
The Department covers abortions when the life of the mother would be endangered
if the fetus were carried to term for which federal financial participation is
currently available under Title XIX of the Social Security Act and the Nebraska
Medicaid State Plan. A physician must certify the diagnosis by medical reports
which include the name and address of the client. The treating physician must
request and receive prior authorization before providing the service from the
Department before providing the service. If approved, the Department will send
a letter of authorization to the provider and retains one copy of the letter of
authorization. In cases of documented emergencies, authorization may be
requested after the service has been provided. All other requirements of this
subsection must be met.
006.09
INFERTILITY. The Department limits coverage for
infertility to diagnosis and treatment of medical conditions when infertility
is a symptom of a suspected medical problem. Reimbursement or coverage is not
available when the sole purpose of the service is achieving a
pregnancy.
006.10
LABOR
AND DELIVERY. The Department covers reasonable and necessary
services associated with pregnancy. Medical care for pregnancy is reimbursable,
beginning with diagnosis of the condition, continuing through delivery, and
ending after the necessary postnatal care, or termination of pregnancy.
Postpartum services are covered for a 60-day period beginning on the day the
pregnancy ends, and any remaining days in the month in which the
60th day falls, for women who were eligible for,
applied for, and received medical assistance on the day the pregnancy ends.
After the infant is delivered, the infant is treated as a separate patient for
reimbursement purposes.
006.10(A)
PHYSICIANS' SERVICES. The Department covers routine
prenatal care, delivery, six weeks post-partum care, and routine urinalysis as
a package service for physicians in accordance with 471 NAC 18. The Department
does not reimburse hospitals for any physicians' services included in the
package service.
006.10(B)
EXCEPTIONS. The Department may make exceptions to
cover hospital outpatient or emergency room services which meet the coverage
criteria for medically necessary services which are not included in the
physicians' package service.
006.10(C)
INPATIENT.
If the patient is admitted as an inpatient, and not released the same day, the
services are considered inpatient services. If the patient is not admitted as
an inpatient, the services are considered outpatient services.
006.11
ALCOHOL AND
CHEMICAL DETOXIFICATION. The Department limits payment for alcohol
and chemical detoxification to medically necessary treatment, subject to the
Department's utilization review. This period includes an average detoxification
period of two to three days with an occasional need for up to five days when
the patient's condition dictates. A detoxification program for a particular
patient may exceed five days and be covered if determined medically necessary
by the Department. The Department does not cover services when the
detoxification needs of an individual no longer require an inpatient hospital
setting.
006.12
OSTEOGENIC STIMULATION. Electrical stimulation to
augment bone repair (osteogenic stimulation) can be performed either invasively
or non-invasively.
006.12(A)
INVASIVE OSTEOGENIC STIMULATION. Invasive devices
provide electrical stimulation directly at the fracture site either through
percutaneously placed cathodes or by implantation of a coiled cathode wire into
the fracture site. For percutaneously-placed cathodes, the power supply is
externally placed and the leads connected to the inserted cathodes. For the
implanted cathode, the power pack is implanted into soft tissue near the
fracture site and subcutaneously connected to the cathode, creating a
self-contained system with no external components. The Department covers use of
the invasive device only for non-union of long bone fractures. The Department
considers non-union to exist only after six months or more have elapsed without
the fracture healing.
006.12(B)
NON-INVASIVE OSTEOGENIC STIMULATION. For the
non-invasive device, opposing pads wired to an external power supply are placed
over the cast. An electromagnetic field is created between the pads at the
fracture site. The Department covers use of the non-invasive device only for:
(i) Non-union of long bone
fractures;
(ii) Failed fusion;
and
(iii) Congenital
pseudarthrosis.
006.13
BIOFEEDBACK
THERAPY. Biofeedback therapy provides visual, auditory or other
evidence of the status of certain body functions so that a person can exert
voluntary control over the functions, and thereby alleviate an abnormal bodily
condition. Biofeedback therapy often uses electrical devices to transform
bodily signals indicative of such functions as heart rate, blood pressure, skin
temperature, salivation, peripheral vasomotor activity, and gross muscle tone
into a tone or light, the loudness or brightness of which shows the extent of
activity in the function being measured. Biofeedback therapy differs from
electromyography, which is a diagnostic procedure used to record and study the
electrical properties of skeletal muscle. However, an electromyography device
may be used to provide feedback with certain types of biofeedback. Biofeedback
therapy is covered by the Department only when it is reasonable and necessary
for the individual patient for muscle re-education of specific muscle groups or
for treating pathological muscle abnormalities of spasticity, incapacitating
muscle spasm, or weakness, and more conventional treatments have not been
successful. This therapy is not covered for treatment of ordinary muscle
tension states, for psychosomatic conditions, or for psychiatric
conditions.
006.14
DIAGNOSTIC SERVICES. All reasonable and necessary
diagnostic tests given for narcolepsy and sleep apnea are covered when the
following criteria are met:
(i) The clinic
must be affiliated with a hospital;
(ii) Patients must be referred to the sleep
disorder clinic by a physician. The clinic must maintain a record of the
attending physician's orders with signatures; and
(iii) The need for diagnostic testing must be
confirmed by medical evidence, e.g., physician examinations and laboratory
tests.
006.14(A) Diagnostic
testing that is duplicative of previous testing done by the attending physician
to the extent the results are still pertinent is not covered. Most patients who
undergo the diagnostic testing are not considered inpatients, although they may
come to the facility in the evening for testing and then leave after their
tests are over. The overnight stay is considered an integral part of these
tests.
006.15
THERAPEUTIC SERVICES. The Department may cover
therapeutic services provided they are standard and accepted services, and are
reasonable and medically necessary for the patient. Sleep disorder clinics must
provide therapeutic services in the hospital outpatient setting. Therapeutic
services will be provided for:
(A) Insomnia
that is not associated with psychiatric disorders;
(B) Nocturnal myoclonus;
(C) Sleep apnea;
(D) Drug dependency;
(E) Shift work and schedule
disturbances;
(F) Restless leg
syndrome;
(G)
Hypersomnia;
(H)
Somnambulism;
(I) Night terrors or
dream anxiety attacks;
(J)
Enuresis; and
(K)
Bruxism.
006.16
CARDIAC STRESS TESTING AND HOSPITAL OUTPATIENT CARDIAC
REHABILITATION PROGRAMS. Stress testing is a covered diagnostic
procedure for evaluating chest pain and as a component in the development of
rehabilitation exercise prescriptions for the treatment of patients with known
cardiac disease provided that during the testing:
(i) A physician is present;
(ii) Emergency equipment is available;
and
(iii) A standard emergency
procedure plan is in effect.
006.16(A)
STRESS
TESTING. The use of stress testing in the absence of any specific
diagnostic or therapeutic purpose is not covered as reasonable and necessary to
the treatment of the patient's condition.
006.16(B)
OUTPATIENT. Outpatient cardiac rehabilitation programs
consisting of individually prescribed physical exercise or conditioning and
concurrent telemetric monitoring. When a program is provided by a hospital to
its outpatients, the service is covered as an outpatient service.
006.16(B)(i)
CARDIAC
REHABILITATION EXERCISE PROGRAM. Hospital outpatient services in
connection with a cardiac rehabilitation exercise program are considered
reasonable and necessary only during that period of time when the patient's
condition is such that the exercises can only be carried out safely under the
direct, continuing supervision of a physician, and in a hospital environment.
The monitoring required in these programs must be carried out by a
hospital-employed nurse trained in cardiac rehabilitation with a physician
overseeing the monitoring. Although on occasion physical therapists or
occupational therapists are involved in these programs, they generally act only
as exercise leaders. These services do not constitute covered physical therapy
or occupational therapy. Since the type of cardiac rehabilitation exercise
program which can be covered requires a hospital setting, this program is not
covered in a skilled nursing facility.
006.16(B)(ii)
COVERAGE
LIMIT. Coverage is limited to 12 weeks (or 36 sessions) of a
monitored exercise program. For coverage beyond a maximum duration of 12 weeks
(or 36 sessions), the provider must submit documentation supporting the
patient's need for additional services. Documentation must include:
(1) Progress report and exercise
sessions;
(2) Diagnosis;
(3) Cardiac history;
(4) Risk factors;
(5) Other medical problems;
(6) Medications;
(7) Allergies;
(8) Personal habits;
(9) Sources of stress, and support system;
and
(10) Treatment plan.
006.17
MEDICAL TRANSPLANTS. The Department covers transplants
including donor services that are medically necessary and defined as
non-experimental by Medicare. If no Medicare policy exists for a specific type
of transplant, the Department will determine whether the transplant is
medically necessary or non-experimental. The Department will cover
transplantation services when performed in a facility approved by Centers for
Medicaid and Medicare as meeting coverage criteria.
006.17(A)
PRIOR
AUTHORIZATION. The Department requires prior authorization of all
transplant services or related donor service before the services are provided.
An exception may be made for emergency situations, in which case verbal
approval is obtained by the Department and the notification of authorization is
sent later. This request for authorization must be submitted in writing or
using the standard electronic Health Care Services Review: Request for Review
and Response transaction (ASC X12N 278) by the physician to the Department. The
Prior Authorization request must include at a minimum:
(i) The patient's name, age, diagnosis,
pertinent past medical history and treatment to this point, prognosis with and
without the transplant, and the procedure(s) for which the authorization is
requested;
(ii) The patient's
Nebraska Medicaid number;
(iii)
Name of hospital, city, and state where the service(s) will be
performed;
(iv) Name of
physician(s) who will perform the surgery, if other than physician requesting
authorization; and
(1) If authorization is
requested for a liver or heart transplant, in addition to the above
information, two physicians must also supply the following statement:
Recommending the transplant; and
(2) Certifying and explaining why a
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.
006.17(B)
SERVICES FOR A NEBRASKA
MEDICAID-ELIGIBLE DONOR. The Department covers medically necessary
services, including laboratory tests directly related to the transplant, for
the Nebraska Medicaid-eligible donor to a Nebraska Medicaid-eligible client.
The services must be directly related to the transplant.
006.17(C)
SERVICES FOR A NEBRASKA
MEDICAID-INELIGIBLE DONOR. The Department covers medically
necessary services, including laboratory tests directly related to the
transplant, for the Nebraska Medicaid-ineligible donor to a Nebraska
Medicaid-eligible client. The services must be directly related to the
transplant and must directly benefit the Nebraska Medicaid transplant client.
Coverage of treatment for complications related to the donor is limited to
those that are reasonably medically foreseeable. Claims must be submitted under
the Nebraska Medicaid-eligible client's case number.
006.17(D) The Department reserves the right
to request any medical documentation from the patient's record to support and
substantiate claims submitted for payment.
006.17(E) The Department is the payor of last
resort.
006.17(F)
HOSPITAL INPATIENT SERVICES. Procurement costs include removal of
organ, transportation, and associated costs. These costs must be
billed by the transplanting hospital on the appropriate claim form or
electronic format and separately identified on the Medicare cost report. The
hospital must submit copies of the actual invoices for procurement costs,
including transportation costs, on the appropriate claim form or electronic
format.
006.17(G)
AMBULATORY ROOM AND BOARD. The Department may cover ambulatory
room and board services for transplant patients and an attendant if
necessary.
006.18
PHYSICIAN SERVICES. Surgeon(s) services will be paid
according to the Nebraska Medicaid Practitioner Fee Schedule. This fee will
include two weeks' routine post-operative care by the designated primary
surgeon. Payment for routine post-operative care will not be made to other
members of the surgical team. Physician services must be billed on Form
CMS-1500 or the standard electronic Health Care Claim: Professional transaction
(ASC X12N 837).
006.19
ITINERANT PHYSICIAN VISITS. The Department covers
non-emergency physician visits provided in a hospital outpatient setting if the
services are:
(i) Provided by an out-of-town
specialist who has a contractual agreement with the hospital. The Department
does not consider general practitioners or family practitioners to be
specialists; and
(ii) Determined to
have been provided in the most appropriate place of service.
006.19(A) The hospital room charge is
considered the technical component of the visit and must be billed on Form
CMS-1450 (UB-92).
006.20
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/caregiver training must occur before placement of infant apnea
monitor. Parent/caregiver training is not reimbursed as a service separate from
infant apnea monitor rental.
006.20(A)
MEDICAL GUIDELINES FOR THE PLACEMENT OF HOME INFANT APNEA
MONITORS. The Department covers home infant apnea monitoring
services for infants, defined as birth through completion of one year of age,
who meet one of the following criteria:
(i)
Infants with one or more apparent life-threatening events (ALTE) requiring
mouth-to-mouth resuscitation or vigorous stimulation. An apparent
life-threatening event (ALTE) is defined as an episode that is frightening to
the observer and characterized by some combination of apnea (central or
occasionally obstructive), color change (usually cyanotic or pallid but
occasionally erythematous or plethoric), marked change in muscle tone (usually
limpness), choking, or gagging. In some cases, the observer fears the infant
has died;
(ii) Symptomatic preterm
infants;
(iii) Siblings of one or
more SIDS victims; or
(iv) Infants
with certain diseases or conditions, such as central hypoventilation,
bronchopulmonary dysplasia, infants with tracheostomies, infants of
substanceabusing mothers, or infants with less severe apparent life-threatening
events (ALTE).
006.20(B)
APPROVAL OF HOME INFANT APNEA MONITOR SERVICE
PROVIDERS. The Department covers rental of home infant apnea
monitors and related supplies provided only by approved providers. To ensure
all home apnea monitoring needs of infants are met, the Department requires the
development of a home infant apnea monitor coordination plan. The coordination
plan is not an individual patient plan; it is an overall program outline for
the delivery of home apnea monitoring services.
006.20(C)
DOCUMENTATION REQUIRED
AFTER INITIAL RENTAL PERIOD. Monitor rental exceeding the first
two-month prescription period requires that an updated physician's narrative
report of patient progress and a statement of continued need accompany the
claim. A new progress report is required every two months. The report must
include:
(i) The number of apnea episodes
during the previous prescription period;
(ii) The results of any tests performed
during the previous prescription period;
(iii) Additional length of time needed;
and
(iv) Any additional information
the physician may wish to provide.
006.20(D)
REMOVING THE INFANT
FROM THE MONITOR. Criteria for removing infants from home infant
apnea monitoring must be based on the infant's clinical condition. A monitor
may be discontinued when apparent life-threatening event (ALTE) infants have
had two periods, each of three months duration, free of significant alarms or
apnea where vigorous stimulation or resuscitation was not needed. Evaluating
the infant's ability to tolerate stress during this time is advisable. The
provider must state the date of removal of the infant monitor on or in the
final claim.
006.20(E)
COVERED AND NON-COVERED COMPONENTS. The Department
does not cover monitors that do not use rechargeable batteries. The Department
does not make separate payment for remote alarms. If provided, payment for a
remote alarm is included in the monitor rental. Apnea monitor belts, lead
wires, and reusable electrodes are covered for rented apnea monitors.
006.20(F)
PNEUMOCARDIOGRAMS. Pneumocardiograms are covered for
diagnostic or evaluation purposes and when required to determine when the
infant may be removed from the monitor. Payment does not include analysis and
interpretation.
006.20(G)
BILLING. The hospital must bill for the technical
component of infant apnea monitor services on the appropriate claim form or
electronic format. The provider of the apnea monitor must state the date of
removal of the infant monitor on the claim.
Physicians' services must be billed as professional services
on a CMS-1500 Form or the standard electronic Health Care Claim: Professional
transaction (ASC X12N 837).
006.21
HOME
PHOTOTHERAPY. The Department covers rental of home phototherapy
(bilirubin) equipment for infants that require phototherapy when neonatal
hyperbilirubinemia is the infant's sole clinical problem when prescribed by and
used under the supervision of a physician. To ensure that home phototherapy
needs of infants are met, the Department requires the development of a
coordination plan. The coordination plan is not an individual patient plan; it
is an overall program outline for the delivery of home phototherapy services.
006.21(A)
APPROVAL OF HOME
PHOTOTHERAPY PROVIDERS. The Department covers rental of home
phototherapy equipment provided by approved providers. Physicians will not be
approved as home phototherapy providers.
006.21(A)(i) The following conditions must be
met prior to initiation of home phototherapy:
(a) History and physical assessment by the
infant's attending physician has occurred. If home phototherapy begins
immediately upon discharge from the hospital, the newborn discharge exam will
suffice;
(b) Required laboratory
studies have been performed, including, complete blood count (CBC), blood type
on mother and infant, direct Coombs, direct and indirect bilirubin;
(c) The physician certifies that the parent
or caregiver is capable of administering home phototherapy;
(d) Parent or caregiver have successfully
completed training on use of the equipment; and
(e) Equipment must be delivered and set up
within 4 hours of discharge from the hospital or notification of provider,
whichever is more appropriate. There must be a 24-hour per day repair or
replacement service available.
006.21(A)(ii) At a minimum, one bilirubin
level must be obtained daily while the infant is receiving home
phototherapy.
006.21(B)
LIMITATIONS ON COVERAGE OF HOME PHOTOTHERAPY SERVICES.
Services will be reimbursed on a daily basis. The Department's daily allowable
fee includes:
(i) Phototherapy unit and all
supplies, accessories, and services necessary for proper functioning and
effective use of the therapy;
(ii)
A minimum of one daily visit to the home by a licensed or certified "health
care professional" as identified by the supplier in the "Coordination Plan."
The daily visits must include:
(1) A brief
home assessment; and
(2) Collection
and delivery of blood specimens for bilirubin testing when ordered by the
physician to be collected in the home. The physician must be informed by the
provider that this service is available. An outside agency or laboratory with
whom the provider contracts for collection and delivery of blood specimens may
not bill the Department directly since payment is included in the daily rental
payment. Daily home visits must occur for home assessment even if the blood
collection is done outside the home.
(iii) Complete caregiver training on use of
equipment and completion of necessary records.
006.21(C)
DISCONTINUING HOME
PHOTOTHERAPY. Home phototherapy services will not be covered if
the bilirubin level is less than 12 mgs at 72 hours of age or older.
006.21(D)
DOCUMENTATION. A physician's narrative report
outlining the client's progress and the circumstances necessitating extended
therapy must be submitted with the claim when billing for home phototherapy
exceeding three days.
006.21(E)
PAYMENT. Payment for home phototherapy services does
not include physician's professional services or laboratory and radiology
services related to home phototherapy. These services must be billed by the
physician or laboratory performing the service. The Department daily rental
payment includes:
(i) Phototherapy unit and
all supplies, accessories, and services necessary for proper functioning and
effective use of the therapy;
(ii)
A minimum of one daily visit to the home by a licensed or certified "health
care professional" is required. The daily visits must include:
(1) A brief home assessment; and
(2) Collection and delivery of blood
specimens for bilirubin testing when ordered by the physician to be collected
in the home. The physician must be informed by the provider that this service
is available. An outside agency or laboratory with whom the provider contracts
for collection and delivery of blood specimens may not bill Medicaid directly
since payment is included in the daily rental payment. Daily home visits must
occur for home assessment even if the blood collection is done outside the
home.
(iii) Complete
caregiver training on use of equipment and completion of necessary
records.
006.21(F)
BILLING REQUIREMENTS. The provider must bill for home
phototherapy daily rental on a single claim and indicate the total number of
rental days as the units of service using the appropriate claim form or
electronic format as outpatient services.
006.22
COORDINATION PLAN
REQUIREMENT FOR CERTAIN SERVICES. Providers of apnea monitoring
services and phototherapy services must maintain, as a part of the provider's
records, a coordination plan, which must include:
(1) An overview of the services provided,
including the provider's charge for the services;
(2) Descriptions and literature on the
equipment and all supplies and accessories provided;
(3) Copies of all forms, instructions, and
record sheets for client use;
(4)
An outline of the training format used to train the client on use of equipment
and other training requirements;
(5) The type and frequency of client contact
and identification and qualifications of personnel conducting client contacts;
and
(6) A statement of the
provider's policy on equipment set-up, servicing, and availability for
consultation on equipment problems.
006.22(A)The provider must notify the
Department of any changes in the coordination plan. After review of the
coordination plan, the provider may be required to amend the coordination
plan.
006.22(B)
APPROPRIATE HOSPITAL SERVICES. Appropriate home infant
apnea monitor services provided by a hospital with an approved infant apnea
monitor coordination plan includes rental of the apnea monitor, trend event
recorder, and ECG/respirator recorder; purchase of related supplies; conversion
of cassette recording to tape for interpretation; and
CO2/hypoxia studies.
006.23
AMBULATORY ROOM AND
BOARD. The Department covers ambulatory room and board as a
related transportation and as follows:
006.23(A)
APPROVAL AS AN
AMBULATORY ROOM AND BOARD PROVIDER. The Department approves only
hospitals as ambulatory room and board providers. To receive the Department
payment, each hospital providing ambulatory room and board services must be
enrolled with the Department as a provider for hospital services.
006.23(A)(i)
PROVIDER
RE-APPROVAL. Each hospital approved by the Department to provide
ambulatory room and board services must seek re-approval of its ambulatory room
and board services from the Department when any of the following occur:
(1) The charge to the Department for
ambulatory room and board services changes;
(2) There is a change in the physical
location of the ambulatory room and board facility or the distance from the
hospital building;
(3) There is a
change in the services the hospital is able to provide to clients in the
ambulatory room and board facility; or
(4) Other substantial changes are made to the
hospital's ambulatory room and board services.
006.23(B)
GUIDELINES. The Department covers ambulatory room and
board services as follows:
(1) Ambulatory
room and board services must be necessary to secure Nebraska Medicaid coverable
services, including medical examinations or treatment.
(2) The Department covers meals when receipt
of Nebraska Medicaid coverable services requires the client to be away from
their home for 12 hours or longer;
(3) The Department covers lodging when an
out-of-town overnight stay is necessary while receiving Nebraska Medicaid
coverable services or if coverage of ambulatory room and board services will
prevent a hospital inpatient stay; and
(4) The Department covers meals and lodging
for up to one day before or after receiving services if extensive travel is
necessary.
(5) The Department
covers up to one person who accompanies the client when the client is
physically or mental unable to travel or wait alone. For example, a child's
parent or guardian.
006.23(B)(i)
Payment for ambulatory room and board services outside these guidelines must be
approved by the Department staff.
006.23(C)
DOCUMENTATION. The hospital must include a statement
that documents the necessity for ambulatory room and board services for a
client or for a client and an attendant on the hospital claim.
006.23(D)
BILLING AND
PAYMENT. The hospital must bill for ambulatory room and board
services provided by a Department-enrolled hospital as an outpatient service on
the appropriate claim form or electronic format and the appropriate Healthcare
Common Procedure Coding System procedure codes. Payment will be made using a
hospitalspecific rate. Payment to the hospital must not exceed its charge for
services provided to the general public.
