Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 20 - PSYCHIATRIC SERVICES FOR INDIVIDUALS AGE 21 AND OLDER
Section 471-20-007 - Adult Inpatient Hospital Psychiatric Services

Universal Citation: 471 NE Admin Rules and Regs ch 20 ยง 007

Current through September 17, 2024

Inpatient hospital psychiatric services for clients 21 and over are medically necessary psychiatric services provided to an inpatient as defined in 471 NAC 10-000. The care and treatment of an inpatient with a primary psychiatric diagnosis must be under the direction of a psychiatrist or physician who meets the state's licensing criteria and is enrolled as a provider with the Department with a primary specialty of psychiatry. Inpatient hospital psychiatric services must be prior-authorized by the Department-contracted peer review organization or management designee. In addition, out-of-state hospitalizations must be approved by the Department.

007.01 Provider Agreement

A hospital which provides inpatient psychiatric services shall complete Form MC-20, "Medical Assistance Hospital Provider Agreement," (see 471-000-91) and submit the completed form to the Department for approval and enrollment as a provider. The hospital shall submit with the provider agreement -

1. A complete description of the psychiatric program and the elements of the program (i.e., policies and procedures, staffing, services, etc.);

2. A statement of the total number of licensed psychiatric beds, as approved by the Nebraska Department of Health and Human Services, Division of Public Health or agency in the state in which the facility is located; a listing of the bed numbers for those licensed psychiatric beds; and the size of the proposed psychiatric unit;

3. Documentation that the inpatient program meets the family-centered, community-based requirements in 471 NAC 20-001;

4. A description of how family psychotherapy services will be provided;

5. A description of how the hospital services will interface with community services for discharge planning and service provision after discharge;

6. A copy of the most recent JCAHO or AOA accreditation survey; and

7. Any other information requested.

Any facility requesting a provider agreement shall make the facility available for an on-site review before issuance of a provider agreement.

007.02 Standards for Participation for Inpatient Hospital Psychiatric Service Providers

A hospital that provides inpatient hospital psychiatric services must meet the following standards for participation to ensure that payment is made only for active treatment. The hospital -

1. Is maintained for the care and treatment of patients with primary psychiatric disorders;

2. Is licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health, or if the hospital is located in another state, the officially designated authority for standard - setting in that state;

3. Is accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or by the American Osteopathic Association (AOA);

4. Meets the requirements for participation in Medicare for psychiatric hospitals;

5. Has in effect a utilization review plan applicable to all Medicaid clients;

6. Must have medical records that are sufficient to permit the Department to determine the degree and intensity of treatment furnished to the client; and

7. Must meet staffing requirements the Department finds necessary to carry out an active treatment program (see 471 NAC 20-007.03).

8. Hospitals must encourage family members to be involved in the assessment of the client, the development of the treatment plan, and all aspects of the client's treatment unless prohibited by the client, through legal action, or because of federal confidentiality laws.

9. Hospitals must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family's schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings.

10. The hospital must document their attempts to involve the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered. These may include, but should not be limited to, including the family via conference telephone calls, using registered letters to notify the family of meetings, and scheduling meetings in the evening and on weekends.

A distinct part of a hospital may be considered a psychiatric unit if it meets the standards for participation, even though the hospital of which it is a part does not.

007.03 Staffing Standards for Participation

The hospital must have staff adequate in number and qualified to carry out an active program of treatment for individuals who are provided services in the hospital. The hospital shall meet the following standards.

1. Hospital Personnel: Hospitals which provide inpatient psychiatric services must be staffed with the number of qualified professional, technical, and supporting personnel, and consultants required to carry out an intensive and comprehensive active treatment program that includes evaluation of individual and family needs; establishment of individual and family treatment goals; and implementation, directly or by arrangement, of a broad-range therapeutic program including, at least, professional psychiatric, medical, surgical, nursing, social work, psychological, and activity therapies required to carry out an individual treatment plan for each patient and their family. The following standards must be met:
a. Qualified professional and technical personnel must be available to evaluate each patient at the time of admission, including diagnosis of any intercurrent disease. Services necessary for the evaluation include -
(1) Laboratory, radiological, and other diagnostic tests;

(2) Obtaining psychosocial data;

(3) A complete family assessment (see 20-001 and 20-007.07, #7);

(4) Carrying out psychiatric and psychological evaluations; and

(5) Completing a physical examination, including a complete neurological examination when indicated, shortly after admission;

b. The number of qualified professional personnel, including consultants and technical and supporting personnel, must be adequate to ensure representation of the disciplines necessary to establish short-range and long-term goals; and to plan, carry out, and periodically revise a treatment plan for each client based on scientific interpretation of -
(1) The degree of physical disability and indicated remedial or restorative measures, including nutrition, nursing, physical medicine, and pharmacological therapeutic interventions;

(2) The degree of psychological impairment and appropriate measures to be taken to relieve treatable distress and to compensate for nonreversible impairments where found;

(3) The capacity for social interaction, and appropriate nursing measures and milieu therapy to be undertaken, including group living experiences, occupational and recreational therapy, and other prescribed activities to maintain or increase the individual's capacity to manage activities of daily living; and

(4) The environmental and physical limitations required to protect the client's health and safety with a plan to compensate for these deficiencies and to develop the client's potential for return to his/her own home, a foster home, a skilled nursing facility, a community mental health center, or other alternatives to full-time hospitalization.

2. Director of Inpatient Psychiatric Services and Medical Staff: Inpatient psychiatric services must be under the supervision of a clinical director, service chief, or the equivalent who is qualified to provide the leadership required for an intensive treatment program. The number and qualifications of physicians must be adequate to provide essential psychiatric services. The following standards must be met:
a. The clinical director, service chief, or equivalent must meet the training and experience requirements for a psychiatrist or a physician for NMAP;

b. The medical staff must be qualified legally, professionally, and ethically for the positions to which they are appointed; and

c. The number of physicians must be commensurate with the size and scope of the treatment program.

d. The physician's personal involvement in all aspects of the client's psychiatric care must be documented in the client's medical record (i.e., physician's orders, progress notes, nurses notes).

e. The physician must be available, in person or by telephone, to provide assistance and direction as needed.

3. Availability of Physicians and Other Personnel: Physicians and other appropriate professional personnel must be available at all times to provide necessary medical, surgical, diagnostic, and treatment services, including specialized services. If medical, surgical, diagnostic, and treatment services are not available within the hospital, qualified consultants or attending physicians must be immediately available, or a satisfactory arrangement must be established for transferring patients to a general hospital certified for Medicare.

4. Nursing Services: Nursing services must be under the direct supervision of a registered professional nurse who is qualified by education and experience for the position. The number of registered professional nurses, licensed practical nurses, and other nursing personnel must be adequate to formulate and carry out the nursing components of a treatment plan for each client. The following standards must be met:
a. The registered professional nurse supervising the nursing program must have a master's degree in psychiatric or mental health nursing or its equivalent from a school of nursing accredited by the National League for Nursing, or must be qualified by education or experience in the care of the mentally ill, and have demonstrated competence to -
(1) Participate in interdisciplinary formulation of treatment plans;

(2) Give skilled nursing care and therapy; and

(3) Direct, supervise, and train others who assist in implementing and carrying out the nursing components of each client's treatment plan;

b. The staffing pattern must ensure the availability of a registered professional nurse 24 hours each day for -
(1) Direct care;

(2) Supervising care performed by other nursing personnel; and

(3) Assigning nursing care activities not requiring the services of a professional nurse to other nursing service personnel according to the client's needs and the preparation and competence of the nursing staff available;

c. The number of registered professional nurses, including nurse consultants, must be adequate to formulate a nursing care plan in writing for each client and to ensure that the plan is carried out; and

d. Registered professional nurses and other nursing personnel must be prepared by continuing in-service and staff development programs for active participation in interdisciplinary meetings affecting the planning or implementation of nursing care plans for patients. The meetings include diagnostic conferences, treatment planning sessions, and meetings held to consider alternative facilities and community resources.

5. Psychological Services: The psychological services must be under the supervision of a licensed psychologist. The psychology staff, including consultants, must be adequate in numbers and be qualified to plan and carry out assigned responsibilities. The following standards must be met:
a. The psychology department or service must be under the supervision of a licensed psychologist;

b. Psychologists, consultants, and supporting personnel must be adequate in number and be qualified to assist in essential diagnostic formulations, and to participate in -
(1) Program development and evaluation of program effectiveness;

(2) Training and research activities;

(3) Therapeutic interventions, such as milieu, individual, or group therapy; and

(4) Interdisciplinary conferences and meetings held to establish diagnoses, goals, and treatment programs;

c. Psychotherapy must be ordered and directed by a physician; and

6. Social Work Services and Staff: Social work services must be under the supervision of a qualified social worker. The social work staff must be adequate in numbers and be qualified to fulfill responsibilities related to the specific needs of individual clients and their families, the development of community resources, and consultation with other staff and community agencies. The following standards must be met:
a. The director of the social work department or service must have a master's degree from an accredited school of social work and must meet the experience requirements for certification by the Academy of Certified Social Workers and, effective 9-1 -94, must be licensed by the Nebraska Department of Health and Human Services, Division of Public Health as a mental health practitioner; and

b. Social work staff, including other social workers, consultants, and other assistants or case aides, must be qualified and numerically adequate to -
(1) Provide psychosocial data for diagnosis and treatment planning, and for direct therapeutic services to patients, patient groups, or families; to develop community resources, including family or foster care programs; to conduct appropriate social work research and training activities; and to participate in interdisciplinary conferences and meetings concerning diagnostic formulation and treatment planning, including identification and utilization of other facilities and alternative forms of care and treatment.

7. Qualified Therapists, Consultants, Volunteers, Assistants, Aides: Qualified therapists, consultants, volunteers, assistants, or aides must be sufficient in number to provide comprehensive therapeutic activities, including occupational, recreational, and physical therapy, as needed, to ensure that appropriate treatment is provided to each client, and to establish and maintain a therapeutic milieu. The following standards must be met:
a. Occupational therapy services must be provided preferably under the supervision of a graduate of an occupational therapy program approved by the Council on Education of the American Medical Association who is licensed by the Nebraska Department of Health and Human Services, Division of Public Health or is eligible for the National Registration Examination of the American Occupational Therapy Association. In the absence of a full-time, fully-qualified occupational therapist, an occupational therapy assistant may function as the director of the activities program with consultation from a fully-qualified occupational therapist;

b. When physical therapy services are offered, the services must be given by or under the supervision of a qualified physical therapist who is a graduate of a physical therapy program approved by the Council on Medical Education of the American Medical Association in collaboration with the American Physical Therapy Association or its equivalent and is licensed by the Nebraska Department of Health and Human Services, Division of Public Health. In the absence of a full-time, fully-qualified physical therapist, physical therapy services must be available by arrangement with a certified local hospital, or by consultation or part-time services furnished by a fully-qualified physical therapist;

c. Educational Program Services: Services, when required by law, must be available. Educational Services must only be one aspect of the treatment plan, not the primary reason for admission or treatment. Educational services are not covered for payment by the Nebraska Medical Assistance Program;.

d. Recreational or activity therapy services must be available under the direct supervision of a member of the staff who has demonstrated competence in therapeutic recreation programs;

e. Other occupational therapy, recreational therapy, activity therapy, and physical therapy assistants or aides must be directly responsible to qualified supervisors and must be provided special on-the-job training to fulfill assigned functions;

f. The total number of rehabilitation personnel, including consultants, must be sufficient to -
(1) Permit adequate representation and participation in interdisciplinary conferences and meetings affecting the planning and implementation of activity and rehabilitation programs, including diagnostic conferences; and

(2) Maintain all daily scheduled and prescribed activities, including maintenance of appropriate progress records for individual clients; and

g. Volunteer service workers must be -
(1) Under the direction of a paid professional supervisor of volunteers;

(2) Provided appropriate orientation and training; and

(3) Available daily in sufficient numbers to assist clients and their families in support of therapeutic activities.

007.04 Coverage Criteria for Inpatient Hospital Services

The Nebraska Medical Assistance Program covers inpatient hospital psychiatric services for clients age 21 and over when the services meet the criteria in 471 NAC 20-001 and when the following requirements are met:

1. The attending physician must personally and face-to-face evaluate the client and write the psychiatric evaluation and diagnosis formulation;

2. The client must be treated by a physician personally and face-to-face six out of seven days and the interaction must be documented in the client's clinical record;

3. A psychiatrist or physician for NMAP serves as the attending physician and defines the medical necessity and active treatment requirements noted in 471 NAC 20-001, "General Requirements";.

4. The treatment plan must be developed and supervised by a multi-disciplinary team under the direction and supervision of the physician. It must be implemented upon admission and must be reviewed every 30 days or more often if medically necessary by the multi-disciplinary team. Treatment plans must meet the medical necessity and active treatment requirements in 471 NAC 20-001;

5. Therapeutic passes for clients with primary psychiatric diagnoses from hospitals which provide psychiatric services. Therapeutic passes are an essential part of the treatment of some psychiatric clients. Documentation of the client's continued need for psychiatric care must follow the overnight therapeutic passes. Payment for hospitalization after a second pass is not available based on medical necessity. The hospital is not paid for therapeutic passes or leave days;

6. Unplanned leaves of absence from inpatient and psychiatric hospital care: The hospital is not paid for unplanned leave of absence days. The Department contracted peer review organization or management designee must be notified immediately when the client returns. Admission criteria will be applied. If approved, a new validation number will be issued to cover the days beginning with the day of return.

20-007.04A Professional and Technical Components for Hospital Diagnostic and Therapeutic Services: For regulations regarding professional and technical components for diagnostic and therapeutic hospital services, the elimination of combined billing, and non-physician services and items provided to hospital patients, see 471 NAC 10-003.05C, 10-003.05D, 10-003.05E, and 10-003.05F.

007.05 Admission Criteria for Inpatient Hospital Psychiatric Services

One or more of the following problems must be present:

1. The patient needs a specific form of psychiatric treatment that can only be provided in the hospital and the structured environment of the hospital is necessary for the client's treatment;

2. Specific observations are needed for evaluation and disposition;

3. Specific observations are needed for following treatment, or control of behavior is necessary for effective somatic therapy or psychotherapy;

4. The client's disorder is a serious threat to his/her adaptation to life and continuing developmental process, and hospitalization at this time is necessary to control this factor;

5. The patient is experiencing psychiatric symptoms, the magnitude of which is not tolerable to self or society and that cannot be alleviated through treatment;

6. The patient is unable to be cared for by self or others, due to psychiatric disorder;

7. All patients must require and receive "active treatment" as defined in 42 CFR 441.154, which is available only in an inpatient setting. Exception: Clients are 65 and older in an IMD (see 471 NAC 20-008); or

8. Ambulatory care services in the community do not meet the treatment needs of the client. Note: In those communities where outpatient resources are not available, the community pattern of referral must be used when appropriate.
20-007.05A Guidelines for Interpretation: Admission of an individual age 21 and older to an acute care facility or an acute level of care may be made only after all resources at a less restrictive level have been explored and deemed inappropriate.

The following will not be accepted as adequate medical indicators for hospital inpatient admission:

1. Non-availability of group home, halfway house, residential treatment or other placement alternatives;

2. Admission to support or arrange placement in group home, halfway house, or residential treatment;

3. Admission solely for emergency placement or protective custody;

4. Admission due to failure of current placement;

5. Reason for acute level of care is to obtain Medicaid benefits that would otherwise not be reimbursed;

6. Admission to avoid placement in the criminal justice system;

7. Admission for conduct disorders or behavioral issues that do not demonstrate an imminent danger to self or others;

8. Social and family problems; and

9. Psychometric evaluation including mental retardation and learning disabilities.

20-007.05A1 Patient Assessment: Admission to an acute care facility must meet elements #1 and #2 (listed below) plus at least one other element from this patient assessment section. The additional element must be as a result of the major psychiatric disorder referred to in element #1. In addition, one element from the acute services section must be met.

* Elements #1 and #2 must be met on all admissions.

1. Documented evidence of a major psychiatric disorder that necessitates 24-hour medical supervision and daily physician contact.

2. Documented initial treatment plan with provisions for -
a. Resolution of acute medical problems;

b. Evaluation of, and needs assessment for, medications;

c. Protocol to ensure patient's safety;

d. Discharge plan initiated at the time of admission.

* Plus one of the following:

3. Demonstrates imminent danger to self or others at the time of admission evidenced by at least one of the following:
a. Suicide attempt or specific suicide plan with access to means;

b. Danger to others through a specific action or activity;

c. Command hallucination with suicidal or homicidal content;

d. Hallucinations, delusional behavior, or other bizarre psychotic behavior.

4. Presence of other behavior/symptoms to such a degree or in such a combination that acute care is the least restrictive treatment available as demonstrated by at least one of the following:
a. Physical aggression toward family, peers, or coworkers which could not be considered self protective;

b. Explosive behavior without provocation or serious loss of impulse control;

c. Dangerous, assaultive, uncontrolled or extreme impulsive behavior which puts the patient at significant risk, e.g., running into traffic, playing/setting fires, self-abuse, and which cannot be prevented in a non-acute setting;

d. Severe impairment in concentration and/or hyperactivity;

e. Behaviors consistent with an acute psychiatric disorder which may include significant mental status changes; and there is documented evidence that no medical condition would account for the symptoms;

5. Severe impairment in psychosocial functioning as demonstrated by at least one of the following:
a. Psychotic behavior, delusions, paranoia, or hallucinations;

b. Severe decompensation and interference with baseline functioning;

6. Documented failure of current intensive outpatient treatment including two or more of the following indications:
a. Intensification or perseverance of severe psychiatric symptoms;

b. Noncompliance with medication regime;

c. Lack of therapeutic response to medication;

d. Lack of patient participation in or response to outpatient treatment modalities;

7. Admissions ordered by the court will be covered when accompanied by substantiation of medical necessity.

Documentation supports the need for controlled, clinical observation and psychiatric evaluation, where acute care is the least restrictive treatment alternative.

20-007.05A2 Acute Services:

Justification for Continued Stay: The patient must meet elements #1 and #2 plus two elements from 2 through 7 for the approval of continued stay.

* Elements #1 and #2 must be met at all continued stay reviews.

1. Evidence of a major psychiatric disorder that necessitates 24-hour medical supervision and family physician contact.

2. A comprehensive treatment plan/clinical pathway of inpatient care must be completed within 72 hours of admission and implemented to facilitate the patient's progression toward living in a less supervised setting. Documentation must support the patient's and/or family's active involvement with the treatment goals and with revisions in the treatment plan as appropriate based on the patient's progress or lack of progress.

* Plus two of the following:

3. Isolation, seclusion, or restraint procedures within the last 72 hours requiring 24-hour medical supervision and supported by medical record documentation.

4. Continuing evidence of symptoms and/or behaviors reflecting significant risk, imminent danger, or actual demonstrated danger to self or others; requiring suicide/homicide precautions (1:1) , close observation, step down precautions (every 15-60 minute checks).

5. Monitoring/adjustment of psychotropic medication(s) related to lack of therapeutic effect/complication(s) in the presence of complicating medical and psychiatric conditions necessitating 24-hour medical supervision and supported by medical record documentation.

6. Persistence of psychotic symptoms and continued temporary (not chronic) inability of the patient to perform the activities of daily living or meet their basis needs for nutrition and safety due to a psychiatric disorder or the temporary mental state of the patient.

7. Continued need for 24-hour medical supervision, reevaluation and/or diagnosis of a patient exhibiting behaviors consistent with acute psychiatric disorder. Referral for physician review is necessary if symptoms are unimproved or worse within any seven-day interval.

20-007.05B Signs and Symptoms: In addition to the admission criteria, one or more of the following signs or symptoms of the problem must be present:
1. A suicide attempt that requires acute medical intervention or suicidal ideation with a lethal plan and the means to carry out this plan;

2. Psychiatric decompensation to a level in which the client is not able to communicate or perform life-sustaining activities of daily living;

3. Delusions or hallucinations that significantly impair the client's ability to communicate or perform life-sustaining activities of daily living;

4. Catatonia;

5. The presence of combined illnesses where neurological or other disease process coexists with a psychiatric disturbance, demanding special diagnostic or treatment interventions, which exceed non-hospital capacity;

6. Aggression to others causing physical injury or homicidal ideation with a lethal plan and the means to carry out the plan, that is the result of a severe emotional psychiatric decompensation; and

7. Medication initiation or change when the client has a documented history of reactions to psychotropic medications that have resulted in the need for acute medical care in a hospital or an emergency room.

007.06 Prior Authorization Procedures

All inpatient admissions must be prior-authorized by the Department-contracted peer review organization or management designee. Each client will have a specific prior-authorization number assigned by the Department contracted peer review organization or management designee if the admission is approved. Providers should follow the Department's contracted peer review organization or management designee guidelines on facilitating prior authorization.

007.07 Documentation in the Client's Clinical Record

The medical records maintained by a hospital permit determination of the degree and intensity of the treatment provided to clients who receive services in the hospital. For inpatient hospital psychiatric services, clinical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the client is hospitalized. The medical record must by legible and include -

1. The identification data, including the client's legal status (i.e., voluntary admission, Board of Mental Health commitment, court mandated);

2. A provisional or admitting diagnosis which is made on every patient at the time of admission and includes the diagnoses of intercurrent diseases as well as the psychiatric diagnoses;

3. The complaint of others regarding the client, as well as the client's comments;

4. The psychiatric evaluation, including a medical history, which contains a record of mental status and notes the onset of illness, the circumstances leading to admission, attitudes, behavior, estimate of intellectual functioning, memory functioning, orientation, and an inventory of the client's strengths in a descriptive, not interpretative, fashion;

5. A complete neurological examination, when indicated, recorded at the time of the admitting physical examination;

6. A social history sufficient to provide data on the client's relevant past history, present situation, social support system, community resource contacts, and other information relevant to good treatment and discharge planning;

7. A family assessment as described in 471 NAC 20-001;

8. Reports of consultations, psychological evaluations, electroencephalograms, dental records, and special studies;

9. The client's treatment plan and treatment plan reviews;

10. The treatment received by the client, which is documented in a manner and with a frequency to ensure that all active therapeutic efforts, such as individual, group, and family psychotherapy, drug therapy, milieu therapy, occupational therapy, recreational therapy, nursing care, and other therapeutic interventions, are included;

11. Progress notes which are recorded by the psychiatrist or physician, nurse, social worker, and, when appropriate, others significantly involved in active treatment modalities. The frequency is determined by the condition of the client, but progress notes must be recorded daily by nursing staff, and at each contact by psychiatrist or physician and by all other therapeutic staff (such as O.T., R.T.). Progress notes must contain a concise assessment of the client's progress and recommendations for revising the treatment plan as indicated by the client's condition;

12. The psychiatric diagnosis contained in the final diagnosis written in the terminology of the current American Psychiatric Association's Diagnostic and Statistical Manual;

13. Therapeutic leave days prescribed by the psychiatrist under the treatment plan. The client's response to time spent outside the hospital must be entered in the client's hospital clinical record;

14. Transition and discharge planning documentation;

15. Proof of family and community involvement;

16. A copy of the MC-14 certification; and

17. The discharge summary, including a recapitulation of the client's hospitalization, recommendations for appropriate services concerning follow-up, and a brief summary of the client's condition on discharge.

All documents from the client's medical record submitted to the Department must contain sufficient information for identification (i.e., client's name, date of service, provider's name).

007.08 Certification and Recertification by Psychiatrists for Inpatient Hospital Psychiatric Services

20-007.08A Certification and Recertification by Psychiatrists: The Department pays for covered inpatient hospital psychiatric services only if a psychiatrist or physician certifies, and recertifies at designated intervals, the medical necessity for the services of the hospital inpatient stay. Appropriate supporting material may be required. The psychiatrist's or physician's certification or recertification statement must document the medical necessity for the admission to and continued hospitalization for inpatient psychiatric treatment, based on a current evaluation of the client's condition.

For clients admitted to a hospital, a psychiatrist's or physician's certification by written order for admission is required at the time of admission for inpatient services.

20-007.08B Failure to Certify or Recertify: If a hospital fails to obtain the required certification and recertification statements in an individual case, the Department shall not make payment for the case.

007.09 Hospital Utilization Review (UR)

See 471 NAC 10-012. A site visit by Medicaid staff for purposes of utilization review may be required for further clarification.

007.10 Payment for Inpatient Hospital Psychiatric Services

See 471 NAC 10-010.03.

20-007.10A Billing: Providers shall submit claims for inpatient hospital psychiatric services on Form CMS-1450 or the standard electronic Health Care Claim: Institutional transaction (ASC X12N 837).

007.11 Other Regulations

In addition to the policies regarding psychiatric services, all regulations in the Nebraska Department of Health and Human Services Manual apply, unless stated differently in this section. For inpatient services provided by an IMD, public or private, see 471 NAC 20-008.

007.12 Limitations

For inpatient hospital psychiatric services, the following limitations apply:

1. Care must be supervised by a psychiatrist or physician. All inpatient hospital services must be prior-authorized; and

2. Payment for inpatient hospital services is made according to 471 NAC 10-010.03.

007.13 Form Completion

Inpatient hospital psychiatric service providers shall -

1. Complete Form MC-20 and be approved and enrolled with the Department as a provider of inpatient hospital psychiatric services (class of care 06);

2. Submit all claims for inpatient hospital services on an appropriately completed Form CMS-1450 or the standard electronic Health Care Claim: Institutional transaction (ASC X12N 837);

3. Enter the review number from the Department contracted peer review organization or management designee as required.

Payment for approved services is made to the hospital.

007.14 Exceptions

Additional documentation from the client's medical record may be requested by the Department's psychiatric consultants prior to considering authorization of payment.

007.15 Emergency Protective Custody (EPC) in an Acute Care Hospital

Emergency Protective Custody (EPC) Services may be reimbursed in an acute care hospital without licensed psychiatric beds for an average of three to five days, up to seven days under the following conditions:

1. The hospital is licensed by the Nebraska Department of Health and Human Services, Division of Public Health;

2. The hospital is accredited by the Joint Commission on the Accreditation of Health Care Organizations or the American Osteopathic Association;

3. The admitting and attending physician is a psychiatrist;

4. The hospital provides a setting that is separate from the rest of the hospital activities and is a safe, therapeutic environment;

5. The hospital provides an active treatment program in the form of assessment and diagnostic interventions;

6. The hospital EPC program is approved by the Department's Medicaid staff; and

7. The hospital EPC program meets all other standards for inpatient hospital psychiatric care.

The exception for EPC services is available only to hospitals that do not have licensed psychiatric beds.

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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