Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 13 - NURSING SERVICES
Section 471-13-004 - SERVICE REQUIREMENTS

004.01(A) MEDICAL NECESSITY. The Department incorporates the medical necessity requirements outlined in 471 NAC 1 as if fully rewritten herein. Services and supplies that do not meet the requirements in 471 NAC 1 are not covered004.01(A(i ADDITIONAL REQUIREMENTS.All skilled nursing services must be.

004.01(B) AUTHORIZATION. All skilled nursing services must be authorized and the eligibility of the client must be verified by the provider. The Department or its designee may grant authorization of skilled nursing services. Providers must send requests for authorization electronically using the standard Health Care Services Review - Request for Review and Response transaction (ASC X 12N 278) or by submitting Form MS-81: Certification and Plan of Care For Private-Duty Nursing to the Medicaid designee. Requests must include the physician's order and the plan of care. The plan must include.

004.01(C) ELIGIBILITY AND PHYSICIAN CERTIFICATION. To be eligible for skilled nursing services, the attending physician must certify that based on the client's medical.condition, skilled nursing services are medically necessary and appropriate services to be provided in the home.

004.01(D) SECOND VISIT SAME DAY. The medical necessity of a second visit on the same date of service must be documented. Substantiating documentation must be submitted with MC-82N, or the request for prior authorization with the standard Health Care Claim: Professional Transaction (ASC X12N 837).

004.02(A) USE OF AUTHORIZED HOURS. A client who requires and is authorized to receive home health nursing services in the home setting may use their approved hours outside of the home during those hours when their normal life take them out of the home. The Department will not authorize any additional hours of nursing service beyond what would normally be authorized to cover the client's need for medically necessary and appropriate services provided in the home. If a client requests or requires nursing services to attend school or other activities outside the home, but does not need nursing services in the home during those hours, nursing services will not be authorized.

004.02(B) MEDICATIONS. The Department covers intravenous or intramuscular injections and intravenous feeding. Oral medications are covered only where the complexity of the medical condition (physical or psychological) and the number of drugs require a licensed nurse to monitor, detect and evaluate side effects and compliance. The complexity of the medical condition must be documented and submitted with the plan of care.

004.02(C) ADDITIONAL SERVICES FOR DIABETIC CLIENTS. Medicaid covers blood sugar testing and foot care for blind or disabled clients who are unable to perform this task themselves and where there is no one else available to perform the task on the client's behalf.

004.02(D) DECUBITUS AND SKIN DISORDERS. The Department covers this service when specific physician orders indicate that skilled nursing care is necessary, requiring prescribed medications and treatment.

004.02(E) DRESSINGS. The Department covers application of dressings when aseptic technique and prescription medications are used.

004.02(F) COLOSTOMY, ILEOSTOMY, GASTROSTOMY. The Department covers colostomy, ileostomy, and gastrostomy during immediate postoperative time, including initial teaching, when maintenance care and control by the patient or family is being established.

004.02(G) ENTEROSTOMAL THERAPY. The Department recognizes enterostomal therapy visits as a skilled nursing service.

004.02(H) ENEMAS AND REMOVAL OF IMPACTIONS. The Department covers enemas and removal of impactions when the complexity of the condition of the patient establishes that the skills of a nurse are required.

004.02(I) BOWEL AND BLADDER TRAINING. The Department covers teaching skills and facts necessary to adhere to a specific formal regimen. General routine maintenance program or treating is not covered.

004.02(J) URETHRAL CATHETERS AND STERILE IRRIGATIONS. The Department covers insertions and changes when active urological problems are present or client is unable to do a physician-ordered irrigations. Routine catheter maintenance care is not covered.

004.02(K) OBSERVATION AND EVALUATION. The Department covers observation and evaluation requiring the furnishing of a skilled service for an unstable condition. An unstable condition is evidenced by the presence of one of the following conditions:

004.02(L) CASTS. The Department covers casts if the physician's order evidences more complexity than routine or general supportive care.

004.02(M) DRAW OR COLLECTION OF LABORATORY SPECIMENS. The Department covers the collection of laboratory specimens only if based on the client's medical condition.

004.02(N) TEACHING AND TRAINING ACTIVITIES. The Department covers skilled nursing visits for teaching or training that require the skills or knowledge of a nurse. The Department limits postpartum visits for teaching and training to two visits. The necessity of further visits must be justified by additional documentation evidencing extenuating circumstances which create the need beyond two visits. The client must have a medical condition that has been diagnosed and treated by a physician and there must be a physician's order for the specific teaching and training. Visits are covered on an individual basis. The provider must maintain specific documentation of both the need for the teachingor training, and the training provided. Documentation must be submitted along with the plan of care. Teaching or training can occur in the following areas:

004.02(O) EXTENDED-HOUR NURSING SERVICES. Provision of extended-hour nursing services must be authorized by the Department or its designee. Extended-hour nursing services are authorized only when the client's care needs must be provided by skilled nursing personnel in the absence of the caregiver or parents. Children must have documented medical needs that cannot be met by a traditional child care provider system. When providing extended-hour nursing care, the Department will authorize coverage for a maximum of 56 hours a week, depending upon the complexity of a client's care. A maximum of 12 hours may be approved in a 24-hour period. Changes in the client's condition or schedule of the caregiver or parents may require a reevaluation of the approved nursing hours with written verification.

004.03(A) MEDICATIONS. Medicaid does not cover injections that can be self-administered; drugs not considered an effective treatment for a condition given; anddrugs for which a medical reason does not exist for providing the drug by injection rather than by mouth.

004.03(B) DECUBITUS AND SKIN DISORDERS. The Department does not cover preventative and palliative measures, and decubiti which are minor, usually Stage I, or Stage II.

004.03(C) TEACHING AND TRAINING ACTIVITIES. The Department does not cover visits made solely to remind or emphasize the need to follow instructions or when services are duplicated.

004.03(D) DRESSINGS. Visits made to dress non-infected closed postoperative wounds or chronic controlled conditions are not covered.