Current through September 17, 2024
003.01
APPROVAL. Payment for medical care and services
through Medicaid funds must be approved by the Department.
003.01(A)
CONDITIONS FOR
APPROVAL. Claims will be approved for payment when all of the
following conditions are met:
(i) The
provider was enrolled and eligible for payment under the Nebraska Medicaid
State Plan on the date the service was provided;
(ii) The client was eligible for Medicaid
when the service was provided, or the service was provided during the period of
retroactive eligibility;
(iii) No
more than 6 months have elapsed from the date of service when the claim is
received by the Department (see 471 NAC 3-002.01A for exceptions);
(iv) The medical care and services are within
the guidelines of Medicaid;
(v) The
client's clinical record must contain information to meet state requirements;
and
(vi) A trading partner
agreement has been approved, if required, for clearinghouses, billing agents,
and providers submitting claims using electronic transactions.
003.01(B)
EXCEPTIONS
TO TIMELY FILING OF CLAIMS. Payment may be made by the Department
for claims received more than six months after the date of service if the
circumstances which delayed the submittal were beyond the provider's control.
The Department will determine whether the circumstances were beyond the
provider's control based on documentation submitted by the provider.
003.01(C)
TIMELY PAYMENT OF
CLAIMS. The Department must pay claims within 12 months of the
date of receipt of the claim. This time limitation does not apply to:
(i) Retroactive adjustments paid to providers
who are reimbursed under a retrospective payment system;
(ii) Claims which have been filed in a timely
manner for payment by Medicare, for which the Department may pay a Medicaid
claim relating to the same services. Claims for the Medicaid portion must be
submitted to the Department within six months from the date of the Medicare
remittance advice;
(iii) Claims
from providers under investigation for alleged fraud or abuse;
(iv) Payments made:
(1) In accordance with a court
order;
(2) To carry out hearing
decisions or agency corrective actions taken to resolve a dispute;
(3) To extend the benefits of a hearing
decision, corrective action, or court order to others in the same situation as
those directly affected by it; or
(4) Third party casualty situations as
specified in 471 NAC 3-004.06C.
003.01(D)
DENIAL.
The Department will not pay claims received more than two years after the date
of service, except under the circumstances specified in this chapter.
003.01(E)
PROVIDER'S FAILURE TO
COOPERATE IN SECURING THIRD PARYTY PAYMENT. The Department may
deny payment of a provider's claims if the provider fails to apply third party
payments to medical bills, to file necessary claims, or to cooperate in matters
necessary to secure payment by insurance or other liable third
parties.
003.02
PAYMENT.
003.02(A)
UPPER LIMITS. The Department has established upper
limits for payment as described in each provider chapter.
003.02(B)
COVERAGE
EXCEPTION. Certain medical services, while being medically
necessary, may exceed the Nebraska Medicaid coverage guidelines which have been
established by the Department. Under these circumstances, the determination of
medical necessity for payment purposes is based upon the professional judgment
of the Department's consultants and other appropriate staff.
003.02(C)
PAYMENT IN
FULL. Providers participating in Nebraska Medicaid agree to accept
as payment in full the amount paid according to the Department's payment
methodologies after all other sources have been exhausted.
003.02(C)(i)
EXCEPTION. If a client resides in a nursing facility,
a payment to the facility for the client to occupy a single room is not
considered income in the client's budget if Medicaid is or will be paying any
part of the nursing facility care.
003.02(D)
CHARGES TO THE GENERAL
PUBLIC. Providers will not exceed their charges to the general
public when billing the Department. A provider who offers a discount to certain
individuals will apply the same discount to Medicaid clients who would
otherwise qualify for the discount.
003.02(E)
METHOD OF
PAYMENT. Payment for all approved medical services within the
scope of Nebraska Medicaid will be made by electronic funds transfer to the
provider who supplied the services.
003.02(F)
BILLED
CHARGES. If the provider's billed charges are less than the
Department's allowable payment, the Department pays the provider's billed
charges.
003.02(F)(i)
EXCEPTION. Inpatient hospital services are paid on a
diagnosis-related group or per diem basis, regardless of billed
charges.
003.03
POST-PAYMENT
REVIEW. Payment for a service does not indicate compliance with
Department policy. Monitoring is accomplished by post-payment review to verify
Department policy has been followed. A refund will be requested if post-payment
review finds payment has been made for claims or services not in compliance
with Department policy. During a post-payment review, claims submitted for
payment may be subjected to further review or not processed pending the outcome
of the review.
003.04
PAYMENT FOR MEDICAL EXPENSES. Payment may not be made
from Department funds for medical expenses which have been paid from public or
private sources.
003.05
SHARE OF COST. Individuals who are otherwise eligible
but who have excess income must obligate the excess amount for medical care
before payment for medical services can be approved through Nebraska
Medicaid.
003.05
ADJUSTMENTS TO PAYMENT REDUCTIONS OR DISALLOWANCES.
Providers are restricted to a maximum time limitation of 90 days to request an
adjustment to a claim, regardless of the reason for the adjustment or whether
the claim was disallowed in part or in whole, unless documentation of
extenuating circumstances is submitted to and approved by the Department. The
90-day limitation begins with the payment date of the paper remittance advice
or with the payment date of the electronic remittance advice.
003.06
REFUNDS.
003.06(A)
REFUNDS REQUESTED BY
THE DEPARTMENT. When the Department requests a refund of all or
part of a paid claim, the provider is allowed 30 days to refund the amount
requested, to show the refund has already been made, to document why the refund
request is in error, or appeal. The provider's failure to respond within 30
days is cause for the Department to recoup from future provider payments until
the refund is paid in full or to sanction the provider. The refund request
constitutes notice of the sanction to recoup from future payments. Refunds
resulting from third party resource payment must also be made as required in
this chapter.
003.06(B)
THIRD PARTY LIABILITY REFUNDS. When third party
liability payments are received after a claim has been submitted to the
Department, the provider must refund the Department within 30 days. The refund
must be accompanied by a copy of the documentation, such as the explanation of
benefits or electronic coordination of benefits.
003.06(C)
PROVIDER REFUNDS TO THE
DEPARTMENT. Providers have the responsibility to review all
payments to ensure no overpayments have been received. The provider must refund
all overpayments to the Department within 30 days of identifying the
overpayment.
003.07
ADMINISTRATIVE FINALITY. Administrative decision or
inaction in the allowable cost determination process for any provider, which is
otherwise final, may be reopened by the Department within three years of the
date of notice of the decision or inaction in order to examine the accuracy of
a determination which is otherwise final. The Director is the sole authority in
deciding whether to reopen.
003.07(A)
SITUATIONS ALLOWING FOR REOPEN. Action to reopen may
be taken:
(i) On the initiative of the
Department within the three-year period;
(ii) In response to a written request from a
provider or other entity within the three-year period. Whether the Director
will reopen a determination, which is otherwise final, depends on whether new
and material evidence has been submitted, a clear and obvious error has been
made, or the determination is found to be inconsistent with the law,
regulations and rulings, or general instructions; or
(iii) At any time fraud or abuse is
suspected.
003.07(B)
FAIR HEARING. The right to a fair hearing does not
apply to a finding by the Director which indicates a reopening or correction of
a determination or decision is not warranted.
003.08
BILLING THE
CLIENT. Providers participating in Nebraska Medicaid agree to
accept payment from the Department as payment in full. The provider will not
bill the client for Nebraska Medicaid covered services if the claim is denied
by the Department for lack of medical necessity or for failure to follow a
procedural requirement. The provider will not bill the client for services
covered by Nebraska Medicaid. It is not a violation of Department regulations
for the provider to bill the client for services not covered by Nebraska
Medicaid. It is not a violation for a provider to bill the client for services
when it is determined the client has received money from a third party resource
and the money was designated to pay medical bills. If the client agrees in
advance in writing to pay for the non-covered service, the provider may bill
the client.
003.08(A)
VERIFICATION OF ELIGIBILITY. The provider has the
responsibility to verify the client's eligibility for Medicaid and any
limitations which apply to a specific client.
003.09
SECTION 1122
SANCTIONS. When the United States Department of Health and Human
Services imposes a sanction under section 1122 of the Social Security Act and
instructs the Department to withhold or recoup the federal share of the capital
expenditure, the Department will withhold the federal and the state share of
the capital expenditure.
