Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 10 - HOSPITAL SERVICES
Section 471-10-007 - BILLING AND PAYMENT FOR HOSPITAL SERVICES
Universal Citation: 471 NE Admin Rules and Regs ch 10 ยง 007
Current through September 17, 2024
007.01 PAYMENT.
007.01(A)
GENERAL PAYMENT REQUIREMENTS. The Department will
reimburse the Provider for services rendered in accordance with the applicable
payment regulations codified in 471 NAC 10. In the event that individual
payment regulations in 471 NAC 3 conflict with payment regulations outlined in
this 471 NAC 10, the individual payment regulations in 471 NAC 10 must
govern.
007.01(B)
SPECIFIC PAYMENT REQUIREMENTS.
007.01(B)(i)
OUTPATIENT
SERVICES. The Department provides reimbursement for hospital
outpatient services provided to Nebraska Medicaid eligible clients on a
prospective basis in accordance with the rate methodology for Outpatient
Hospital and Emergency Room Services. Reimbursement for the following services
is included in the prospective rate payment for hospital inpatient services:
(a) Technical Component of Hospital
Outpatient Radiology Services;
(b)
Non-Patient Radiology Services;
(c)
Anesthesiology:
(i) Technical Component of
Medical Direction of Four or Fewer Concurrent Procedures for hospital
outpatient;
(ii) Technical
component of outpatient anesthesiology services provided by anesthetists who
are not employees of a physician; and
(d) Medical Transplants, hospital charges for
ambulatory stays.
007.01(B)(i)(1)
This list is not intended to be an exclusive list of services that are
reimbursed as a part of the hospital prospective payment for outpatient
services. Other services that are considered to be included within the scope of
services that are reimbursed as a part of the prospective payment for
outpatient services include, but are not limited to, the following:
(a) Services which are customarily reimbursed
as a part of the prospective payment for outpatient services.
007.01(B)(ii)
INPATIENT SERVICES. The Department provides
reimbursement for hospital inpatient services provided to Nebraska Medicaid
eligible clients on a prospective basis. Each facility, with the exception of
critical access hospitals, must receive a prospective rate in accordance with
the Department's outlined rate methodology for hospital inpatient services.
Reimbursement for the following services is included in the prospective rate
payment for hospital inpatient services:
(a)
Hospital observation services when the client is thereafter admitted as an
inpatient of the same hospital;
(b)
Hospital outpatient or emergency room services when the client is thereafter
admitted as an inpatient of the same hospital before midnight of the same
day;
(c) Non-physician inpatient
services and Items:
(i) Outpatient and
emergency room services provided by the hospital before admission;
and
(ii) Outpatient or inpatient
services provided by another hospital or freestanding medical facility to an
inpatient of the original admitting facility.
(iii) Payment for durable medical equipment,
orthotics, and prosthetics, etc., for hospital inpatients is included in the
hospital's payment for inpatient services.
(d) Labor and delivery: The Department
utilizes the current Medicare methodology in accounting for labor and delivery
charges on the Medicare cost report;
(e) Technical component of inpatient clinical
laboratory services: The hospital may include these costs on its cost report to
be considered in calculating the hospital's payment rate;
(f) Technical component of inpatient
anatomical pathology services: The hospital may include these costs on its cost
report to be considered in calculating the hospital's payment rate;
(g) Technical component of hospital inpatient
radiology services: These costs may be included on the hospital's cost report
to be considered in calculating the hospital's payment rate;
(h) Anesthesiology:
(i) Technical component of medical direction
of four or fewer concurrent procedures for hospital;
(ii) Technical component of inpatient
anesthesiology services provided by anesthetists who are not employees of a
physician;
(i) Inpatient
dialysis: The hospital may include the costs of inpatient dialysis services on
it cost report to be considered in calculation the hospital payment
rate.
(j) Pre-Admission
Testing;
(k) Medical transplants:
(i) Hospital inpatient services, including
procurement costs;
(ii) Technical
component of inpatient laboratory and diagnostic and therapeutic
radiology;
(l) Infant
apnea monitoring services provided to an inpatient.
007.01(B)(ii)(1) This list is not intended to
be an exclusive list of services that are reimbursed as a part of the hospital
prospective payment for inpatient services. Other services that are considered
to be included within the scope of services that are reimbursed as a part of
the prospective payment for inpatient services include, but are not limited to,
the following:
(a) Services which are
included by a hospital in the Medicare cost report; or
(b) Services which are customarily reimbursed
as a part of the prospective payment for inpatient services.
007.01(B)(iii)
RECONCILIATION TO FACILITY UPPER PAYMENT LIMIT.
Facilities will be subject to a preliminary and a final reconciliation of
Nebraska Medicaid payments to allowable Nebraska Medicaid costs. Facilities
will have 90 days to make refunds to the Department, when notified that an
overpayment has occurred.
007.01(B)(iv)
TRANSFERS. When a patient is transferred to or from
another hospital, the Department will make a transfer payment to the
transferring hospital if the initial admission is determined to be medically
necessary.
007.01(B)(v)
INPATIENT ADMISSION AFTER OUTPATIENT SERVICES. A
patient may be admitted to the hospital as an inpatient after receiving
hospital outpatient services. Inpatient services, for billing and payment
purposes, includes the following:
(a)
Non-physician outpatient services rendered on the day of admission or during
the inpatient stay;
(b) Diagnostic
services rendered up to three days before the day of admission; and
(c) Admission related non-diagnostic services
rendered up to 3 days before the day of admission. The day of the admission as
an inpatient is the first day of the inpatient hospitalization.
007.01(B)(v)(1)
READMISSIONS. The Department adopts Medicare peer
review organization (PRO) regulations to control increased admissions or
reduced services. All Nebraska Medicaid patients readmitted as an inpatient
within 31 days will be reviewed by the Department or its designee. Payment may
be denied if either admissions or discharges are performed without medical
justification as determined by medical review.
007.01(B)(vi)
INTERIM PAYMENT FOR
LONG-STAY PATIENTS. A hospital may request an interim payment if
the patient has been hospitalized 60 days and is expected to remain
hospitalized an additional 60 days. To request an interim payment, the hospital
must send the appropriate claim form or electronic format to the Department
indicating the hospital days for which the interim payment is being requested
with an attestation by the attending physician that the patient has been
hospitalized a minimum of 60 days and is expected to remain hospitalized a
minimum of an additional 60 days.
007.01(B)(vi)(1)
FINAL PAYMENT
FOR LONG-STAY PATIENT. When an interim payment is made for
long-stay patients, the hospital must submit a final billing for payment upon
discharge of the patient. Upon discharge, payment for the entire
hospitalization will be calculated at the same rate as all prospective
discharge payments. The final payment will be reduced by the amount of the
interim payment.
007.01(B)(vii)
PAYMENT FOR
NON-PHYSICIAN ANESTHETIST (CRNA) FEES. Hospitals which meet the
Medicare exception for payment of certified registered nurse anesthetist (CRNA)
fees as a pass-through by Medicare will be paid for certified registered nurse
anesthetist (CRNA) fees in addition to their prospective per discharge
payment.
007.01(B)(viii)
NON-PAYMENT FOR HOSPITAL ACQUIRED CONDITIONS. The
Department will not make payment for those claims which are identified as
nonpayable by Medicare as a result of avoidable hospital complications and
medical errors that are identifiable, preventable, and serious in their
consequences to patients. This provision applies only to those claims in which
the Department is a secondary payor to Medicare.
007.01(B)(ix)
OUT-OF-PLAN
SERVICES. When Managed Care enrollees are provided hospital
inpatient services by Nebraska Medicaid enrolled facilities not under contract
with the Department's managed care organizations (MCO), the managed care
organizations (MCO) are authorized, but are not required, to pay for the care
provided at rates the Department would otherwise reimburse providers.
007.01(B)(x)
LOWER LEVELS OF
CARE. When the Department determines that a client no longer
requires inpatient services but requires skilled nursing care and there are no
skilled nursing beds available when the determination is made, the Department
will pay only for authorized medically necessary skilled nursing care provided
in an acute care hospital at a rate equal to the average rate per patient day
paid by the Department to skilled nursing facilities during the previous
calendar year. Medically necessary skilled nursing care must be authorized
within 15 days of admission.
007.01(B)(x)(1)
When a Nebraska Medicaid patient no longer requires inpatient hospital services
and has requested nursing home admission and is waiting for completion of the
pre-admission screening process (PASP), the Department may pay for the
pre-admission screening process (PASP) days the client remains in the hospital
before the pre-admission screening process is completed at a rate equal to the
average rate per patient day paid by the Department to skilled nursing
facilities during the previous calendar year.
007.01(B)(x)(2) The hospital must request
prior authorization from the Department before the pre-admission screening
process (PASP) days are provided. The Department will send the authorization to
the hospital. Pre-admission screening process (PASP) days will not be
considered in computing the hospital's prospective rate.
007.01(C)
PAYMENTS FOR PSYCHIATRIC SERVICES. Tiered rates will
be used for all psychiatric services, regardless of the type of hospital
providing the service. This includes services provided at a facility enrolled
as a provider for psychiatric services which is not a licensed psychiatric
hospital or a Medicare-certified distinct part unit. Payment for each discharge
equals the applicable per diem rate times the number of approved patient days
for each tier. Payment is made for the day of admission, but not the day of
discharge. Mental health and substance abuse services provided to clients
enrolled in managed care for the mental health and substance abuse benefits
package will be reimbursed by the managed care organization (MCO).
007.01(C)(i)
PAYMENT FOR HOSPITAL
SPONSORED PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF). The
Department reimbursement is capped at the psychiatric residential treatment
facilities (PRTF) usual and customary daily charges billed for eligible
clients. Public psychiatric residential treatment facilities (PRTF) will be
cost-settled annually. Payment rates do not include costs of providing
educational, pharmacy and physician services.
007.01(C)(ii)
PAYMENT FOR
PSYCHIATRIC ADULT INPATIENT SUBACUTE HOSPITAL SERVICES. Payments
for psychiatric adult inpatient subacute hospital services are made on a per
diem basis. The subacute inpatient hospital per diem rate is not a tiered rate.
Payment will be an all-inclusive per diem, with the exception of physician
services.
007.01(C)(iii)
RATES FOR STATE-OPERATED INSTITUTIONS FOR MENTAL DISEASE
(IMD). Institutions for mental disease (IMD) operated by the State
of Nebraska will be reimbursed for all reasonable and necessary costs of
operation. State-operated institutions will receive an interim per diem payment
rate, with an adjustment to actual costs following the cost reporting
period.
007.01(C)(iv)
FREE-STANDING PSYCHIATRIC HOSPITALS. When a
free-standing psychiatric hospital (in Nebraska or out of state) does not have
ancillary services onsite, such as pharmacy or laboratory, the provider of the
ancillary service must bill the Department for the ancillary services provided
to inpatients.
007.01(D)
PAYMENT FOR SERVICES FURNISHED BY A CRITICAL ACCESS HOSPITAL
(CAH). The Department reimburses the reasonable cost of providing
the services, as determined under applicable Medicare principles of
reimbursement, except that the following principles do not apply: the lesser of
costs or charges (LCC) rule, ceilings on hospital operating costs, and the
reasonable compensation equivalent (RCE) limits for physician services to
providers. Subject to the 96-hour average on inpatient stays in critical access
hospitals (CAH), items and services that a critical access hospitals (CAH),
provides to its inpatients are covered if they are items and services of a type
that would be covered if furnished by a hospital to hospital
inpatients.
007.01(E)
DISPROPORTIONATE SHARE HOSPITALS. A hospital qualifies
as a disproportionate share hospital if the hospital meets the definition of a
disproportionate share hospital and submits the required information completed,
dated and signed as follows with their Medicare cost report:
(i) The names of at least two obstetricians
who have staff privileges at the hospital and who have agreed to provide
obstetric services to individuals who are eligible for Nebraska Medicaid. This
requirement does not apply to a hospital:
(1)
The inpatients of which are predominantly individuals under 18 years of age;
or
(2) Which does not offer
non-emergency obstetric services to the general population as of December 21,
1987.
(3) For a hospital located in
a rural area, the term "obstetrician" includes any physician with staff
privileges at the hospital to perform non-emergency obstetric
procedures.
(ii) Only
Nebraska hospitals which have a current enrollment with Nebraska Medicaid will
be considered for eligibility as a Disproportionate Share Hospital.
007.01(F)
DEPRECIATION. The Department recognizes depreciation
as an allowable cost as reported on each facility's Medicare cost report and as
determined allowable by the Medicare intermediary through application of
Medicare principles of reimbursement.
007.01(F)(i)
RECAPTURE OF
DEPRECIATION. A hospital which is sold for a profit and has
received Nebraska Medicaid payments for depreciation must refund to the
Department the lower of:
(1) The amount of
depreciation allowed and paid by the Department; or
(2) The product of:
(a) The ratio of Nebraska Medicaid allowed
inpatient days to total inpatient days; and
(b) The amount of gain on the sale as
determined by the Medicare.
007.01(F)(ii) The year(s) for which
depreciation is to be recaptured is determined by the Medicare Intermediary
according to Medicare principles of reimbursement.
007.01(G)
ADJUSTMENT TO
RATE. Changes to Nebraska Medicaid total allowable costs as a
result of error, audit, or investigation may become the basis for adjusting
current or prior prospective rates. The adjustment will be made back to the
initial date of payment for the period affected based on the rate as determined
by the Department. Hospitals will receive written notice of any adjustment
stating the amount of the adjustment and the basis for the adjustment. If the
rate adjustment results in decreasing a hospital's rate, the hospital must
refund the overpayment amount as determined by the Department to the
Department. If the rate adjustment results in increasing a hospital's rate, the
Department will reimburse the underpayment amount as determined by the
Department to the hospital.
007.01(G)(i)
REQUEST FOR RATE ADJUSTMENTS. Hospitals may submit a
request to the Department for an adjustment to their rates for the following:
(1) An error in the calculation of the
rate;
(2) Extraordinary
circumstances. Extraordinary circumstances are limited to:
(a) Changes in routine and ancillary costs,
which are limited to:
(i) Intern and resident
related medical education costs; and
(ii) Establishment of a subspecialty care
unit;
(b) Extraordinary
capital-related costs. Adjustment for capital-related costs will be limited to
no more than a five percent increase; or
(3) Catastrophic circumstances. Hospitals may
submit a request for adjustment to their rate if they incur allowable costs as
a consequence of a natural or other catastrophe. The following circumstances
must be met to be considered a catastrophic circumstance:
(a) One-time occurrence;
(b) Less than twelve-month
duration;
(c) Could not have been
reasonably predicted;
(d) Not of an
insurable nature;
(e) Not covered
by federal or state disaster relief; and
(f) Not a result of malpractice or
negligence.
007.01(G)(ii)
ADJUSTMENT
CONDITIONS. In all circumstances, requests for adjustments to
rates must be calculable and auditable. Requests must specify the nature of the
adjustment sought and the amount of the adjustment sought. The burden of proof
is that of the requesting hospital. If an adjustment is granted, the peer group
rates will not be changed. In making a request for adjustment for circumstances
other than a correction of an error, the requesting hospital must demonstrate
the following:
(1) Changes in costs are the
result of factors generally not shared by other hospitals in Nebraska, such as
improvements imposed by licensing or accrediting standards, or extraordinary
circumstances beyond the hospital's control.
(2) Every reasonable action has been taken by
the hospital to mitigate or contain resulting cost increases. The Department
may request that the hospital provide additional quantitative and qualitative
data to assist in evaluation of the request. The Department may require an
on-site operational review of the hospital be conducted by the Department or
its designee.
(3) The rate the
hospital receives is insufficient to provide care and service that conforms to
applicable state and federal laws, regulations, and quality and safety
standards.
007.07(H)
ACCESS TO
RECORDS. Hospitals must make all records relating to the care of
Nebraska Medicaid patients and any and all other cost information available to
the Department, its designated representatives or agents, or representatives of
the federal Department of Health and Human Services, upon reasonable notice
during regular business hours.
007.01(H)(i)
ADDITIONAL CONDITIONS. Hospitals must allow authorized
representatives of the Department, the federal Department of Health and Human
Services, and state and federal fraud and abuse units to review and audit the
hospital's data processing procedures and supportive software documentation
involved in the production of computer-encoded claims submitted to the
Department. The hospital must allow the authorized representatives access for
the purpose of audit and review at any reasonable time during normal working
hours upon written notice by the Department at least one working day before the
review and audit.
007.01(J)
COST REPORT
AUDITS. The Department periodically performs or receives cost
report audits to monitor the accuracy of data used to set rates. Audits may be
performed by the hospital's Medicare intermediary, the Department, or an
independent public accounting firm, licensed to do business in Nebraska and
retained by the Department. Audits will be performed as determined appropriate
by the Department.
007.02(J)(i)
NON-PARTICIPATING HOSPITALS. A hospital that does not
participate in the Medicare program will complete the Medicare cost report in
compliance with Medicare principles and supporting rules, regulations, and
statutes. The hospital will file the completed form with the Department within
five months after the end of the hospital's reporting period. A 30-day
extension of the filing period may be granted if requested in writing before
the end of the five-month period. Completed Medicare Cost Reports are subject
to audit by the Department or its designees. Note: If a nursing facility (NF)
is affiliated with the hospital, the nursing facility (NF) cost report must be
filed according to 471 NAC 12. Note specifically that the time guidelines for
filing nursing facility (NF) cost reports differ from those for
hospitals.
007.01(K)
PROVIDER APPEALS. A hospital may submit additional
evidence and request prompt administrative review of its prospective rate
within 90 days of the rate notification date according to the procedures in 471
NAC 2. A hospital may also request an adjustment to its rate.
007.01(L)
PAYMENT TO
HOSPITAL-AFFILIATED AMBULATORY SURGICAL CENTERS (HAASC). The
Department pays for services provided in a hospital-affiliated ambulatory
surgical center (HAASC) according to 471 NAC 10 unless the hospital-affiliated
ambulatory surgical center (HAASC) is a Medicare-participating ambulatory
surgical center (ASC). If the hospital-affiliated ambulatory surgical center
(HAASC) is a Medicare-participating ambulatory surgical center (ASC), payment
is made according to 471 NAC 26.
007.01(M)
PAYMENT FOR OUTPATIENT
MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES IN A HOSPITAL. The
Department pays for covered outpatient mental health services, except for
laboratory services, at the lower of:
(i) The
provider's submitted charge; or
(ii) The allowable amount for that procedure
code in the Nebraska Medicaid Practitioner Fee Schedule for that date of
service.
007.01(N)
APPROVAL OF PAYMENT FOR EMERGENCY ROOM SERVICES. At
least one of the following conditions must be met before the Department
approves payment for use of an emergency room:
(1) The patient is evaluated or treated for
an emergency medical condition;
(2)
The patient's evaluation or treatment in the emergency room results in an
approved inpatient hospital admission. The emergency room charges must be
displayed on the inpatient claim as ancillary charges and included in the
inpatient per diem; or
(3) The
patient is referred by his or her physician for treatment in an emergency room.
007.01(N)(i) When the facility or
the Department determine services are non-emergent, the room fee for
non-emergent services provided in an emergency room will be disallowed to 50
percent of what would otherwise be allowed. All other Nebraska Medicaid
allowable charges incurred in this type of visit will be paid according to 471
NAC 10.
007.01(P)
PAYMENT TO A NEW HOSPITAL FOR OUTPATIENT SERVICES. The
Department must cost-settle claims for Nebraska Medicaid-covered services which
are paid by the Department. The cost settlement will be the lower of costs or
charges as reflected on the hospital's cost report. The Department's payment
must not exceed the upper limit of the provider's charges for services. Upon
the Department's receipt of the hospital's initial Medicare cost report, the
Department must no longer consider the hospital to be a "new hospital" for
payment of outpatient services.
007.01(Q)
PAYMENT TO AN
OUT-OF-STATE HOSPITAL FOR OUTPATIENT SERVICES. Payment to an
out-of-state hospital for outpatient services will be made based on the
statewide average ratio of cost to charges for all Nebraska
hospitals.
007.01(R)
ADMINISTRATIVE FINALITY. See 471 NAC 3.
007.01(S)
LIMITATIONS ON PAYMENT
FOR HOSPITAL SERVICES.
007.01(S)(i)
PLACE OF
SERVICE. The department may review, reduce, or deny payment for
covered outpatient or emergency room drugs, supplies, or services which could
have been provided in a less expensive setting.
007.01(S)(ii)
ITEMS NOT UTILIZED
IN THE FACILITY. Drugs, medical supplies, and services prescribed
at discharge from the hospital must be obtained from and billed by the
appropriate provider. The Department does not provide payment to a hospital for
drugs, supplies, and services prescribed at discharge from the hospital for
nursing home residents. Payment for these items is included in the nursing home
per diem.
007.01(S)(iii)
OUTPATIENT/EMERGENCY SERVICES ON THE SAME DAY AS INPATIENT
SERVICES. When a client receives outpatient or emergency room
hospital services and is thereafter admitted as an inpatient of the same
hospital before midnight of the same day, the outpatient/emergency room
hospital services are treated as inpatient services for billing
purposes.
007.01(S)(iv)
BILLED CHARGES. Inpatient hospital services are paid
on a prospective rate basis, regardless of billed charges.
007.01(T)
THE DEPARTMENT'S
SURVEILLANCE AND UTILIZATION REVIEW OF HOSPITAL SERVICES. The
Department, or its designee, reviews hospital inpatient services for:
(1) Medical necessity, appropriateness of
service, and level of care;
(2)
Validation of hospital diagnosis and procedure coding information;
(3) Completeness, adequacy and quality of
care;
(4) Appropriateness of
admission, continued hospitalization, discharge, and transfer; or
(5) Appropriateness of prospective payment
outlier cases.
007.01(T)(i)
REVIEW ACTIVITIES FOR HOSPITAL INPATIENT SERVICES REIMBURSED ON A
PROSPECTIVE PER DISCHARGE BASIS. All hospital inpatient services
reimbursed on a prospective per discharge basis are subject to random
retrospective review by the Department or its designee. Admissions within three
calendar days of a hospital outpatient service may be included in the sample.
In addition to the random sample, focused reviews of inpatient stays for
transplant(s) or neonatal intensive care unit (NICU) stays provided in a
subspecialty care facility or cost outliers may be done by the Department or
its designee.
007.01(T)(i)(1)
REVIEW FOR ALL SELECTED CASES. Validation will
include:
(a) Validation of diagnostic and
procedural information and ICD-9-CM coding;
(b) Medical necessity for inpatient admission
and procedure(s);
(c) Stability at
discharge; and
(d) Quality of
care.
007.01(T)(i)(2)
PAYMENT REDUCTION. If the Department, or its designee,
determines that either admissions or discharges are performed without medical
justification, payment for inpatient services may be denied. Payment can be
reduced if coding inaccuracies are identified by the Department or its
designee. Any cost outlier which is not determined to be medically necessary
for hospital inpatient care by the Department or its designee may qualify for
payment as a lower level of care payment.
007.01(T)(ii)
REVIEW ACTIVITIES
FOR HOSPITAL INPATIENT SERVICES REIMBURSED ON A PROSPECTIVE PER DIEM
BASIS. Hospital inpatient care must be reasonable, medically
necessary, and appropriate for the class of care being billed. All hospital
inpatient admissions must be certified by the Department or its designee prior
to payment. Review will include medical necessity, appropriateness of service,
and level of care. Payment for services will be denied if the Department or its
designee determines the service was not medically necessary. The Department or
its designee will conduct these activities through pre-admission, concurrent,
and retrospective reviews. If the class of care is not appropriate, the claim
may be reduced to the appropriate level of care according to 471 NAC 10 or
denied.
007.01(T)(iii)
SURVEILLANCE AND UTILIZATION REVIEW OF HOSPITAL OUTPATIENT
SERVICES. Claims for payment for hospital outpatient services are
subject to review by the Department or its designee. Hospital outpatient care
must be reasonable and medically necessary, and must be provided in the most
appropriate place of service.
007.02 BILLING.
007.02(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 NAC 3 conflict with billing requirements outlined in this
471 NAC 10, the individual billing requirements in 471 NAC 10 must
govern.
007.02(B)
SPECIFIC BILLING REQUIREMENTS. Providers of hospital
services must submit claims to the Department on Form CMS-1450.
007.02(B)(i)
MEDICARE
COVERAGE. For a Medicare/Medicaid client, the provider must bill
Medicare for appropriate benefits before submitting a claim to the Department
except Medicare non-covered services covered by the Department.
007.02(B)(i)(1)
MEDICARE PART
B. If the Medicare/Medicaid client has exhausted their Medicare
Part A benefits, the hospital must bill these services or items to Medicare
Part B if the client is covered by Part B before billing the Department. The
hospital must enter the amount approved by Medicare as a prior payment on Form
CMS-1450 or by electronic format.
007.02(B)(ii)
DOCUMENTATION. The Department requires that
documentation, when required, be submitted with each claim for hospital
services. Documentation must be complete and legible. All Nebraska Medicaid
clients sign a release of information statement when they apply for Nebraska
Medicaid. If the hospital requires another release, the hospital must obtain
that release based on the provider agreement with the Department.
007.02(B)(iii)
HOSPITAL-ACQUIRED
CONDITIONS (HAC). Effective for inpatient and inpatient crossover
claims with a 'From' date of service on or after the effective date of this
regulation, hospitals are required to report whether each diagnosis on a
Nebraska Medicaid claim was present at the time of patient admission, or
present on admission (POA). Claims submitted without the required present on
admission (POA) indicators will be denied.
007.02(B)(iii)(1) For claims containing
diagnoses that are identified by Medicare as hospital-acquired conditions,
other than deep vein thrombosis (DVT)/pulmonary embolism (PE) following total
knee replacement or hip replacement surgery in pediatric and obstetric patients
and for which the condition was not present on admission (POA), these diagnoses
will not be used for All Patient Diagnostic Related Group grouping. The claim
will be paid as though any diagnoses included in the list of hospital-acquired
conditions (HAC) were not present on the claim. The Department denies payment
for any hospital-acquired conditions (HAC) that results in death or serious
disability. The Department does not make additional payments for services on
inpatient hospital claims that are attributable to hospital-acquired conditions
(HAC) and are coded with present on admission (POA) indicator codes "N" or "U".
Specifically, for hospitals paid under the:
(i) Diagnostic related group (DRG) payment
method, the Department does not make additional payments for complications and
comorbidities (CC) and major complications and comorbidities (MCC).
(ii) Cost to Charges (CCR) payment method,
the Department does not pay for charges attributable to the hospital-acquired
conditions (HAC).
(iii) Per Diem
payment method, the Department will limit provider payment reductions to the
extent that the identified PPC would otherwise result in an increase in
payment, or if the Department can reasonably isolate for nonpayment the portion
of the payment directly related to the PPC.
007.02(B)(iv)
OTHER PROVIDER
PREVENTABLE CONDITION (OPPC). Effective for inpatient, inpatient
crossover, outpatient, and outpatient hospital claims, payment will be denied
for the following other provider preventable conditions:
(1) Incorrect surgical or other invasive
procedure performed on a patient;
(2) Incorrect surgical or other invasive
procedure performed on the wrong body part;
(3) Incorrect surgical or other invasive
procedure performed on the wrong patient.
007.02(B)(v)
NURSERY
CARE. Hospitals reimbursed by per diem must bill nursery care
unless the newborn:
(1) Is transferred from
nursery bassinet care to acute care or intensive care; or
(2) Remains in the hospital after the
mother's discharge, if the child is being discharged to the mother's
care.
007.02(B)(vi)
HOSPITAL UTILIZATION REVIEW (UR). Each hospital must
have in effect a utilization review plan that provides for review of services
provided by the hospital and by members of the medical staff to Nebraska
Medicaid patients.
007.02(B)(vi)(1)
COMPOSITION OF THE UTILIZATION REVIEW COMMITTEE. A
utilization review (UR) committee consisting of two or more practitioners must
carry out the utilization review (UR) function. This commitee must be:
(i) A staff committee of the institution;
or
(ii) A group outside the
institution established by the local medical society and some or all of the
hospitals in the locality or established in a manner approved by the Centers
for Medicare and Medicaid Services.
007.02(B)(vi)(1)(a)
SMALL
INSTITUTION. If, because of the small size of the institution, it
is impossible to have a properly functioning staff committee, the utilization
review (UR) committee must be established under item two above. The committee's
or group's reviews may not be conducted by any individual who has a direct
financial interest in that hospital or was professionally involved in the care
of the patient whose case is being reviewed. At least two members of the
committee must be doctors of medicine or osteopathy. The other members may be:
(i) A doctor of medicine or
osteopathy;
(ii) A doctor of dental
surgery or dental medicine;
(iii) A
doctor of podiatric medicine;
(iv)
A doctor of optometry; or
(v) A
chiropractor.
007.02(B)(vi)(2)
SCOPE AND
FREQUENCY OF REVIEWS. The utilization review (UR) plan must
provide for review of Nebraska Medicaid patients with respect to the medical
necessity of:
(i) Admissions to the
hospital;
(ii) The duration of
stays; and
(iii) Professional
services provided, including drugs.
007.02(B)(vi)(2)(a)
REVIEW OF
ADMISSIONS. Review of admissions may be performed before, at, or
after hospital admission. Except for extended stay reviews, reviews may be
conducted on a sample basis.
007.02(B)(vii)
DETERMINATIONS
REGARDING DENIAL OF MEDICAL NECESSITY OF ADMISSIONS OR CONTINUED
STAYS. The determination that an admission or continued stay is
not medically necessary:
(a) May be made by
one member of the utilization review (UR) committee if the practitioner(s)
responsible for the patient's care concur with the determination or fail to
present their view when given the opportunity; or
(b) In all other cases, must be made by at
least two members of the utilization review (UR) committee.
007.02(B)(vii)(1)
MEDICALLY
NECESSARY. Before making a determination that an admission or
continued stay is not medically necessary, the utilization review (UR)
committee must consult the practitioner(s) responsible for the care of the
patient, and afford the practitioner(s) the opportunity to present their views.
If the committee decides that admission to or continued stay in the hospital is
not medically necessary, written notification must be given no later than two
days after the determination, to the hospital, the patient, and the
practitioner(s) responsible for the care of the patient.
007.02(B)(vii)(2)
BILLING THE
CLIENT. The hospital may bill the client for services provided
after the date the client receives notification if the following criteria are
met:
(i) The hospital's utilization review
(UR) committee has determined that an admission or an extended stay is or was
not medically necessary;
(ii) The
hospital has met the client notification requirements in 471 NAC 10;
and
(iii) The Nebraska Medicaid
client chooses to remain in the hospital or be admitted to the hospital.
007.02(B)(vii)(2)(a) PERMISSABLE
BILLING. When an individual is admitted to a hospital as a non-Nebraska
Medicaid patient and is later determined to be eligible for Nebraska Medicaid,
the hospital must not bill the client for services that are covered by the
Department. If the services are covered by the Department but have been denied
based on medical necessity, the provider must not bill the client. The hospital
may bill the client for those services that are specifically not covered by the
Department, such as cosmetic surgery.
007.02(B)(vii)(3)
EXTENDED STAY
REVIEW. The utilization review (UR) committee must make a periodic
review as specified in the utilization review (UR) plan of each current
inpatient receiving hospital services during a continuous period of extended
duration. The scheduling or the periodic reviews may be the same for all cases
or different for different classes of cases.
007.02(B)(vii)(4)
RECERTIFICATION
OF CONTINUED STAY. Recertification must be made at least every 60
days after initial certification. Psychiatric inpatient care must be certified
every 30 days.
007.02(B)(viii)
REVIEW OF
PROFESSIONAL SERVICES. The utilization review (UR) committee must
review professional services provided, to determine medical necessity and to
promote the most efficient use of available health facilities and
services.
007.02(B)(ix)
SWING BEDS. The Department covers swing beds only for
skilled nursing care where a client requires 24-hour professional nursing care.
007.02(B)(ix)(1)
PRIOR
AUTHORIZATION. To obtain prior authorization for payment for a
client admitted to a swing bed, within 15 days of the date of admission to the
swing bed facility staff must:
(a) Complete an
admission Form MC-9-NF or use the standard electronic Health Care Services
Review - Request for Review and Response transaction (ASC X12N 278);
(b) Submit a copy of Form DM-5 or physician's
history and physical;
(c) Complete
Long Term Care Evaluation; and
(d)
Submit all the information to the local office.
007.02(B)(x)
ANCILLARY
SERVICES. The hospital must bill for ancillary services for
swing-bed patients who are eligible for Nebraska Medicaid only. If Medicare is
covering the swing-bed services, the facility must not bill the Department for
ancillary services.
007.02(B)(xi)
THERAPIES. Laboratory, radiology, respiratory therapy,
physical therapy, occupational therapy, and speech pathology and audiology
services must be billed on the appropriate claim form or in electronic format
as outpatient services. These payments must be reported on the Medicare cost
report as outpatient revenues.
Disclaimer: These regulations may not be the most recent version. Nebraska may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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