Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 9 - HOME HEALTH AGENCIES AND SKILLED NURSING SERVICES
Section 471-9-005 - BILLING AND PAYMENT FOR HOME HEALTH AGENCIES

Universal Citation: 471 NE Admin Rules and Regs ch 9 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 2 and 471 NAC 3. In the event the individual billing requirements in 471 NAC 2 and 471 NAC 3 conflict with billing requirements outlined in this chapter, the individual billing requirements in this chapter will govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS.
005.01(B)(i) BILLING INSTRUCTIONS. The provider must bill Medicaid, using the appropriate claim form or electronic format, in accordance with the billing instructions. The signed plan of care must be submitted with the claim. 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. Durable medical equipment and medical supplies are billed under the home health agency provider number.

005.01(B)(ii) PRIVATE DUTY NURSING. Registered nurse (RN) and licensed practical nurse (LPN) providers must submit electronically using the standard Health Care Claim Professional transaction (ASC X12N 837) or use Form MC-82-N: Private Duty Nurse Claim Form. The signed plan of care must be submitted with the claim.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 2 and 471 NAC 3. Providers must comply with all applicable billing requirements codified in 471 NAC 2 and 471 NAC 3. In the event the individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter, the individual payment regulations in this chapter will govern.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS. Medicaid pays for medically prescribed and Department-approved home health agency services provided by Medicare-certified home health agencies.
005.02(B)(i) REIMBURSEMENT. Durable medical equipment and medical supplies are reimbursed according to the payment methodology outlined in 471 NAC 7. Medicaid pays for covered home health agency services and nursing services at the lower of:
(1) The provider's submitted charge;

(2) The allowable amount for each respective procedure in the Nebraska Medicaid Home Health Agency Fee Schedule in effect for that date of service; or

(3) The maximum allowable fee as established by the Department in the Nebraska Medicaid Nursing Services Fee Schedule in effect for that date of service.

005.02(B)(ii) MEDICARE COVERAGE. Medicare coverage is considered to be the primary source of payment for home health agency services for eligible individuals age 65 and older and for certain disabled beneficiaries. Medicaid does not make payment for services denied by Medicare for lack of medical necessity. Medicaid may cover services denied by Medicare for other reasons if the services are within the scope of Medicaid. Claims submitted to the Department for services provided to Medicare-eligible clients must be accompanied by documentation, which verifies the services are not covered by Medicare. To be covered by Medicaid, these services must be provided in accordance with all requirements in limitations outlined in this chapter.

005.02(B)(iii) MEDICAL SUPPLIES. Payment for supplies normally carried in the nursing bag and incidental to the nursing visit is included in the per visit rate. This includes but is not limited to disposable needles and syringes, disposable gloves, applicators, tongue blades, cotton swabs, 4 x 4's, gauze, bandages. Medical supplies not normally carried in the nursing bag may be provided by pharmacies, medical suppliers, or the home health agency under requirements outlined in 471 NAC 7.

005.02(B)(iv) NURSING SERVICES, REGISTERED NURSE (RN) AND LICENSED PRACTICAL NURSE (LPN), FOR ADULTS AGE 21 AND OLDER. In addition to the requirements and limitations outlined in this chapter, Medicaid applies the following limitations to skilled nursing services, for adults age 21 and older:
(1) Per diem reimbursement for skilled nursing services for the care of ventilator-dependent clients must not exceed the average ventilator per diem of all Nebraska nursing facilities, which are providing that service. This average will be computed using nursing facility's ventilator interim rates that are effective January 1 of each year, and are applicable for that calendar year period; and

(2) Per diem reimbursement for all other in-home skilled nursing service will not be changed by the Department for purposes of the Nebraska Medicaid Case Mix System. A record modification may replace an existing record in the Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) data base, but the Department will not replace the existing record in the Nebraska Medicaid Case Mix system. The record modification will be processed by the Department as an original record. This means that the Department will process the record in the usual manner if the record is not already in the Case Mix system. The Department will reject the record as a duplicate if the record has already been accepted into the Case Mix system. The Department will inactivate a discharge or re-entry tracking record but not an assessment. If determined by the Department to be medically necessary, the per diem reimbursement may exceed this maximum for a short period of time. However, in these cases, the 30-day average of the in-home nursing per diems will not exceed the maximum above. The 30 days are defined to include the days which are paid in excess of the maximum plus those days immediately following, totaling 30.

005.02(B)(v) EXTENDED HOME HEALTH HIGH-TECH RATES. High-tech hourly rates are approved when clients require:
(1) Ventilator care;

(2) Tracheostomy care that involves frequent suctioning and monitoring; or

(3) Care and observation of unstable, complex medical conditions requiring advanced nursing knowledge and skills.

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