Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 33 - HEALTH CHECK (EARLY PERIODIC SCREENING, DIAGNOSIS AND TREATMENT [EPSDT]) SERVICES
Section 471-33-005 - BILLING AND PAYMENT FOR HEALTH CHECK SERVICES
Universal Citation: 471 NE Admin Rules and Regs ch 33 ยง 005
Current through September 17, 2024
005.01 BILLING.
005.01(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 NAG 3 conflict with billing
requirements outlined in this 471 NAC 33, the individual billing requirements
in 471 NAC 33 will govern.
005.01(B)
SPECIFIC BILLING
REQUIREMENTS. Providers must bill the Department using Form
CMS-1500 or the standard electronic Health Care Claim: Professional transaction
(ASC X12N 837) for HEALTH CHECK exams, HEALTH CHECK-associated services, and
other comparable exams. The physician or the physician's authorized agent must
submit the physician's usual and customary charge for each procedure code
listed on or in the claim.
005.01(B)(i)
PROCEDURE CODES. Physicians must use Healthcare Common
Procedure Coding System (HCPCS) procedure codes when submitting claims or
encounter data to the Department. Healthcare Common Procedure Coding System
(HCPCS) and Current Procedural Terminology (CPT) procedure codes used by
Medicaid are listed in the Nebraska Medicaid Practitioner Fee
Schedule.
005.01(B)(ii)
VACCINE FOR CHILDREN PROGRAM (VFC) PROGRAM. When a
physician uses federal-purchased vaccine for immunizations, the physician must
bill the Department only for the administration. The physician must use the
modifier "SL" with the vaccine code when billing for the administration. Billed
charges for the administration of Vaccine for Children Program (VFC) vaccines
cannot exceed the state maximum as determined by the federal Vaccine for
Children Program (VFC) program. Contact the Nebraska Vaccine for Children
Program (VFC) program with questions regarding the Nebraska
maximum.
005.02 PAYMENT.
005.02(A)
GENERAL PAYMENT
REQUIREMENTS. The Department will reimburse the Provider for
services rendered in accordance with the applicable payment regulations
codified in 471 NAC 3. in the event that individual payment regulations in 471
NAC 3 conflict with payment regulations outlined in this 471 NAC 33. the
individual payment regulations in 471 NAC 33 will govern.
005.02(B)
SPECIFIC PAYMENT
REQUIREMENTS. The Department pays for covered HEALTH CHECK
services, except for clinical laboratory services or individuals enrolled in
managed care, at the lower of:
(1) The
provider's submitted charge; or
(2)
The allowable amount for that procedure code in the Nebraska Medicaid
Practitioner Fee Schedule for that date of service.
005.02(B)(i)
VACCINE FOR CHILDREN
PROGRAM (VFC) PROGRAM. The Department reimburses for the
administration of Vaccine for Children Program (VFC) vaccine according to the
Nebraska Medicaid Practitioner Fee Schedule.
005.02(B)(ii)
SPECIAL
SERVICES. Payment for special services is made according to the
Nebraska Medicaid Practitioner Fee Schedule unless included as part of a
capitation plan. The Department may also withdraw a provider's approval by
written notification to the provider if the provider no longer meets the
following identified requirements.
005.02(B)(iii)
ENVIRONMENTAL
INVESTIGATION FOR LEAD CONTAMINATION. Payment will be made under
an interagency contract with local or state health departments utilizing a
certified lead inspector at a negotiated rate that includes the initial
environmental investigation and a follow-up visit, if needed.
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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