016.06.06 Ark. Code R. 072

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.06-072 - Title XIX State Plan Amendment 2006-013

ATTACHMENT 3.1-A

AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED

2.

a. Outpatient Hospital Services Non-Emergency Services

Outpatient hospital services other than those which qualify as emergency, outpatient surgical procedures and treatment and therapy services are covered as non-emergency services.

Benefit Limit

Outpatient hospital services are limited to a total of twelve (12) visits a year. This yearly limit is based on the

State Fiscal Year - July 1 through June 30. Outpatient hospital services include the following:

* non-emergency outpatient hospital and related physician and nurse practitioner services

* outpatient hospital therapy and treatment services and related physician and nurse practitioner services

For services beyond the 12 visit limit, an extension of benefits will be provided if medically necessary. The following diagnoses are considered to be categorically medically necessary and do not require prior authorization for medical necessity: Malignant neoplasm; HIV infection; renal failure and pregnancy. All other diagnoses are subject to prior authorization before benefits can be extended.

Outpatient hospital services are not benefit limited for recipients in the Child Health Services (EPSDT) Program.

3. Other Laboratory and X-Ray Services

(1) Other laboratory and X-ray services when ordered and provided by or under the direction of a physician or other licensed practitioner of the healing arts within the scope of his/her practice as defined by State law in the practitioner's office or outpatient hospital setting or by a certified independent laboratory which meets the requirements for participation in Title XVIII. For services above $500.00 per State Fiscal Year for recipients age 21 and older, an extension will be provided if medically necessary. The following diagnoses are considered to be categorically medically necessary and do not require prior authorization for medical necessity: Malignant neoplasm; HIV infection and renal failure. All other diagnoses are subject to prior authorization before benefits can be extended.

The extension procedures do not apply for services provided to recipients under age 21 in the Child Health Services (EPSDT) Program.

(2) Magnetic Resonance Imaging (MRI) and Cardiac Catheterization procedures are exempt from the extension procedures.

(3) Portable X-Ray Services

Services are limited to the following:

! skeletal films involving arms and legs, pelvis, vertebral column and skull;

! chest films which do not involve the use of contrast media; and

! abdominal films which do not involve the use of contrast media.

Services may be provided to an eligible recipient in his/her place of residence upon the written order of the recipient's physician.

Portable X-ray services are included in the extension procedures.

(4) Chiropractor X-Ray Services

! X-ray is limited to two (2) per State Fiscal Year (July 1 through June 30).

2.

a. Outpatient Hospital Services Non-Emergency Services

Outpatient hospital services other than those which qualify as emergency, outpatient surgical procedures and treatment and therapy services are covered as non-emergency services.

Benefit Limit

Outpatient hospital services are limited to a total of twelve (12) visits a year. This yearly limit is based on the

State Fiscal Year - July 1 through June 30. Outpatient hospital services include the following:

* non-emergency outpatient hospital and related physician and nurse practitioner services

* outpatient hospital therapy and treatment services and related physician and nurse practitioner services

For services beyond the 12 visit limit, an extension of benefits will be provided if medically necessary. The following diagnoses are considered to be categorically medically necessary and do not require prior authorization for medical necessity: Malignant neoplasm; HIV infection; renal failure and pregnancy. All other diagnoses are subject to prior authorization before benefits can be extended.

Outpatient hospital services are not benefit limited for recipients in the Child Health Services (EPSDT) Program.

3. Other Laboratory and X-Ray Services

(1) Other laboratory and X-ray services when ordered and provided by or under the direction of a physician or other licensed practitioner of the healing arts within the scope of his/her practice as defined by State law in the practitioner's office or outpatient hospital setting or by a certified independent laboratory which meets the requirements for participation in Title XVIII. For services above $500.00 per State Fiscal Year for recipients age 21 and older, an extension will be provided if medically necessary. The following diagnoses are considered to be categorically medically necessary and do not require prior authorization for medical necessity: Malignant neoplasm; HIV infection and renal failure. All other diagnoses are subject to prior authorization before benefits can be extended.

The extension procedures do not apply for services provided to recipients under age 21 in the Child Health Services (EPSDT) Program.

(2) Magnetic Resonance Imaging (MRI) and Cardiac Catheterization procedures are exempt from the extension procedures.

(3) Portable X-Ray Services

Services are limited to the following:

! skeletal films involving arms and legs, pelvis, vertebral column and skull;

! chest films which do not involve the use of contrast media; and

! abdominal films which do not involve the use of contrast media.

Services may be provided to an eligible recipient in his/her place of residence upon the written order of the recipient's physician.

Portable X-ray services are included in the extension procedures.

(4) Chiropractor X-Ray Services

! X-ray is limited to two (2) per State Fiscal Year (July 1 through June 30).

4.

a. Nursing Facility Services - Not Provided

016.06.06 Ark. Code R. 072

10/26/2006