Certain NMAP clients are required to participate in the
Nebraska Medicaid Managed Care Program known as the Nebraska Health Connection
(NHC). See 471-000-122 for a listing of the NHC plans.
002.01 Health Maintenance Organization (HMO)
Plans
The NHC HMO plans are required to provide, at a minimum,
coverage of services as described in this Chapter. The prior authorization
requirements, payment limitations, and billing instructions outlined in this
Chapter do not apply to services provided to clients enrolled in an NHC HMO
plan with the following exceptions:
1.
Medical Transplants: As defined under 471 NAC
18-004.40, transplants continue to require prior authorization by NMAP and are
reimbursed on a fee-for-service basis, outside the HMO's capitation
payment;
2.
Abortions: As currently defined, abortions continue to
require prior authorization by NMAP and are included in the capitation fee for
the HMO; and
3.
Family
Planning Services: Family planning services do not require a
referral from a primary care physician (PCP). As defined in 471 NAC 18-004.26,
the client must be able to obtain family planning services upon request and
from a provider of choice who is enrolled in NMAP. Family planning services are
reimbursed by the HMO, regardless of whether the service is provided by a PCP
enrolled with the HMO or a family planning provider outside the HMO.
Services provided to clients enrolled in an NHC HMO plan are
not billed to NMAP. The provider shall provide services only under arrangement
with the HMO.
002.02 Primary Care Case Management (PCCM)
Plans
All NMAP regulations apply to services provided to NHC
clients enrolled in a PCCM plan. For services that require prior authorization
under 471 NAC 18-004.01, the provider must obtain prior authorization from the
PCCM plan under the directions for prior authorization of the PCCM plan with
the following exceptions:
1.
Medical Transplants: As define under 471 NAC
18-004.40, transplants are subject to prior authorization by NMAP;
and
2.
Abortions: As currently defined, abortions require
prior authorization by NMAP.
29-002.02A
Referral
Management: When medically necessary services that cannot be
provided by the PCP are needed for the client, the PCP must authorize the
services to be provided by the approved provider as needed with the following
exceptions:
1.
Visual Care
Services: All surgical procedures provided by an optometrist or
ophthalmologist require approval from the PCCM plan. Providers must contact the
client's PCCM primary care physician before providing surgical services.
Non-surgical procedure provided by an optometrist or ophthalmologist do not
require referral/approval from the PCP; however, when an optometrist or
ophthalmologist diagnoses, monitors, or treats a condition, except routine
refractive conditions, the practitioner shall send a written summary of the
client's condition and treatment/follow-up provided, planned, or required to
the client's PCP.
2.
Dental Services: Dentists or oral surgeons providing
medically necessary services not covered under 471 NAC 6-000 must bill that
service on Form CMS-1500 or electronically using the standard Health Care
Claim: Professional transaction (ASC X12N 837), using HCPCS/CPT procedure
codes. These services require referral/ authorization from the client's PCP.
The provider must contact the PCP before providing these services. If a client
requires hospitalization for dental treatment or for medical and surgical
services billed on Form CMS-1500 or electronically using the standard Health
Care Claim: Professional transaction (ASC X12N 837), the provider must_contact
the PCP for referral/authorization.
3.
Family Planning
Services: Family planning services do not require a referral from
the PCP. As defined in 471 NAC 18-004.26, the client must be able to receive
family planning services upon request and from a provider of choice who is
enrolled in NMAP.
002.03 Mental Health and Substance Abuse
Services
Mental health and substance abuse services (MH/SA) are
provided by the MH/SA managed care plan for all NHC clients. This plan includes
the Client Assistance Program (CAP). Clients may access five services annually
with any CAP-enrolled provider without prior authorization. All other MH/SA
services must be prior authorized by the Plan.
