Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 9 - HOME HEALTH AGENCIES
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 March 20, 2024
005.01 BILLING.
005.01(A)
GENERAL BILLING
REQUIREMNTS. Providers must comply with all applicable billing
requirements codified in 471 NAC 3. In the event the individual billing
requirements in 471 NAC Chapter 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)
SUPERVISORY
VISITS. Skilled nursing visits required for the supervision of
licensed practical nurse (LPN) or aide services may not be billed as a skilled
nursing visit. The cost of supervision is included in the payment for the
licensed practical nurse (LPN) or aide service.
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 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 at the lower of:
(1) The provider's submitted charge;
or
(2) The allowable amount for
each respective procedure in the Nebraska Medicaid Home Health Agency 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
471 NAC 13, 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 must not exceed the
average case-mix per diem for the Extensive Special Care 2 case-mix
reimbursement level. This average will be computed using the Extensive Special
Care 2 case-mix nursing facility interim rates, which are effective January 1
of each year, and applicable for that calendar year period.
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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