Section 471-10-006 - LIMITATIONS AND REQUIREMENTS FOR CERTAIN SERVICES006.01PRIOR AUTHORIZATION PROCEDURES. The physician must request prior authorization for these services in writing or the standard electronic Health Care Services Review: Request for Review and Response transaction (ASC X12N 278) prior to providing the service. 006.01(A) REQUEST FOR ADDITIONAL EVALUATIONS. The Department may request additional evaluations when the medical history for the request is questionable or when there is not sufficient information to support the requirements for authorization.006.01(B)PRIOR AUTHORIZATION APPROVAL/DENIAL PROCESS. The prior authorization request review and determination must be completed by one or all of the following Department representatives: (2) Designated Department Program Specialists; and(3) Medical Consultants for the Department for certain specialties.006.01(C)VERBAL AUTHORIZATION PROCEDURES. The Department may issue a verbal authorization when circumstances are of an emergency nature or urgent to the extent that a delay would place the client at risk of receiving medical care. When a verbal authorization is granted, a written request or electronic request using the standard electronic Health Care Services Review: Request for Review and Response transaction (ASC X12N 278) must be submitted within 14 days of the verbal authorization.006.01(D)BILLING AND PAYMENT REQUIREMENTS. Claims submitted to the Department for services defined as requiring prior authorization will not be paid without written or electronic approval from the Department. A copy of the approval letter or notification of authorization issued by the Department must be submitted with all claims related to the procedure or service authorized.006.02HIV TESTING FOR ACQUIRED IMMUNE DEFICIENCY SYNDROME. Payment for HIV testing is limited to medical necessity. 006.02(A)NON-COVERED HIV TESTING. The Department does not pay for HIV testing when there is no history of risk as defined in 471 NAC 10. This includes, but is not limited to, the following: (i) Routine prenatal screening;(ii) Routine pre-operative testing;(iii) Educational or employment requirements;(iv) Entrance requirements for the armed services; and(v) Insurance applications.006.03MINOR SURGICAL PROCEDURES. Reimbursement for excision of lesions of the skin or subcutaneous tissues includes all services and supplies necessary to provide the service. The Department does not make additional reimbursement for suture removal to the physician who performed the initial service or to a hospital. If the sutures are removed by a non-hospital-based physician who is not the physician who provided the initial service, the Department may approve separate payment for the suture removal.006.04TREATMENT FOR OBESITY. The Department will not make payment for services provided when the sole diagnosis is obesity. While obesity is not itself considered an illness, there are conditions which can be caused by or aggravated by obesity. This may include but is not limited to the following: hypothyroidism, Cushing's disease, hypothalamic lesions, cardiac diseases, respiratory diseases, diabetes, hypertension, diseases of the skeletal system. Treatment for obesity can be covered when the services are an integral and necessary part of a course or treatment. 006.04(A)INTESTINAL BY-PASS SURGERY. The Department does not consider this procedure to be reasonable and necessary, and does not cover the procedure.006.04(B)GASTRIC BY-PASS SURGERY FOR OBESITY. Gastric by-pass surgery for patients with extreme obesity can be covered when the surgery is: (a) Medically appropriate for the individual; and(b) Performed to correct an illness which caused the obesity or was aggravated by the obesity. 006.04(B)(i) This procedure must be performed at a facility that is a Bariatric Surgery Center of Excellence.006.05COSMETIC AND RECONSTRUCTIVE SURGERY. The Department covers cosmetic and reconstructive surgical procedures and medical services when medically necessary for the purpose of correcting the following conditions: (i) Limitations in movement of a body part caused by trauma or congenital conditions;(ii) Disfiguring or painful scars in areas that are visible;(iii) Congenital birth anomalies;(iv) Post-mastectomy breast reconstruction; and(v) Other procedures determined to be restorative or necessary to correct a medical condition. 006.05(A)EXCEPTIONS. To determine the medical necessity of the condition, the Department requires prior authorization for cosmetic and reconstructive surgical procedures except for the following conditions: (i) Cleft lip and cleft palate;(ii) Post-mastectomy breast reconstruction;(iii) Congenital hemangioma's of the face; and(iv) Nevus (mole) removals.006.06STERILIZATIONS.006.06(A)COVERAGE RESTRICTIONS. Nebraska Medicaid is prohibited from paying for sterilization of individuals: (i) Under the age of 21 on the date the client signs Form MMS-100; or(ii) Legally incapable of consenting to sterilization.006.06(B)COVERAGE CONDITIONS. The Department covers sterilizations only when: (i) The sterilization is performed because the client receiving the service made a voluntary request for services;(ii) The client is advised at the outset and before the request or receipt of their consent to the sterilization that benefits provided by programs or projects will not be withdrawn or withheld because of a decision not to be sterilized;(iii) Clients whose primary language is other than English must be provided with the required elements for informed consent in their primary language;(iv) Suitable arrangements must be made to communicate the required elements of informed consent to an individual who is blind, deaf, or otherwise handicapped.006.06(C)PROCEDURE FOR OBTAINING SERVICES. Non-therapeutic sterilizations are covered by the Department only when: (1) Legally effective informed consent is obtained on Form MMS-100: Consent Form from the client on whom the sterilization is to be performed. The surgeon must submit a properly completed and legible Form MMS-100 to the Department before payment of claims can be considered; and(2) The sterilization is performed at least 30 days following the date informed consent was given. To calculate this time period, day 1 is the first day following the date on which the form is signed by the client. Day 31 in this period is the first day on which the procedure could be covered by the Department. The consent is effective for 180 days from the date Form MMS-100 is signed. 006.06(C)(i)EXCEPTION. An individual may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery, if at least 72 hours have passed since he or she signed the informed consent for the sterilization. For a premature delivery, the client must have signed the informed consent at least 72 hours before the surgery is performed and at least 30 days before the expected date of delivery; the expected delivery date must be entered on Form MMS-100.006.06(C)(ii)INFORMED CONSENT. Informed consent means the voluntary, knowing assent of the client who is to be sterilized after the individual has been given the following information: (a) A clear explanation of the procedures to be followed;(b) A description of the attendant discomforts and risks that may follow the procedure, including an explanation of the type and possible effects of an anesthetic to be used;(c) A description of the benefits to be expected;(d) Counseling concerning appropriate alternative methods, and the effect and impact of the proposed sterilization including the fact that it must be considered an irreversible procedure;(e) An offer to answer any questions concerning the procedures; and(f) An instruction that the individual is free to withhold or withdraw their consent to the sterilization at any time before the sterilization without prejudicing their future care and without loss of other project or program benefits to which the client might otherwise be entitled;(g) Advice that the sterilization will not be performed for at least 30 days, except under the circumstances; and(h) The individual to be sterilized must be permitted to have a witness of her or his choice present when informed consent was obtained. 006.06(C)(ii)(1)CLIENT RESPONSIBILITY. This information is shown on Form MMS-100, which must be completed by the client.006.07HYSTERECTOMIES. For payment of claims for hysterectomies, the surgeon must submit to the Department Form MMS-101: Informed Consent Form, properly signed and dated by the client in which the patient states that they were informed before the surgery was performed that this surgical procedure results in permanent sterility before claims associated with the hysterectomy can be considered. The completed Form MMS101 must be submitted to the Department, by the surgeon before claims for the hysterectomy can be considered for payment. The Department covers a medically necessary hysterectomy if the following conditions have been met: (i) The person who secured authorization to perform the hysterectomy has informed the individual and her representative, if any, orally and in writing, that the hysterectomy will make the individual permanently incapable of reproducing; and(ii) The individual or her representative, if any, has signed Form MMS-101 acknowledging receipt of that information. 006.07(A)EXCEPTION. The Department does not require informed consent if: (1) The individual was already sterile before the hysterectomy and the physician who performs the hysterectomy certifies in writing that the individual was already sterile before the hysterectomy and states the cause of the sterility.(2) In the case of a post-menopausal woman, the Department considers the woman to be sterile. All claims related to the procedure must indicate that the client is postmenopausal.(3) The individual requires a hysterectomy because of a life-threatening emergency situation in which the physician determines that prior acknowledgment is not possible, and the physician who performs the hysterectomy certifies in writing that the hysterectomy was performed under a life-threatening emergency situation in which the patient determined prior acknowledgment was not possible. The physician must also include certification of the emergency. 006.07(A)(i) A copy of the physician's certification regarding the above exceptions must be submitted to the Department before consideration for payment for claims associated with the hysterectomy can be submitted.006.07(B)NON-COVERED HYSTERECTOMIES. The Department will not cover a hysterectomy if: (i) It was performed solely to make the woman sterile; or(ii) If there was more than one purpose for the procedure, it would not have been performed except to make the woman sterile.006.08ABORTIONS. The Department covers abortions when the life of the mother would be endangered if the fetus were carried to term for which federal financial participation is currently available under Title XIX of the Social Security Act and the Nebraska Medicaid State Plan. A physician must certify the diagnosis by medical reports which include the name and address of the client. The treating physician must request and receive prior authorization before providing the service from the Department before providing the service. If approved, the Department will send a letter of authorization to the provider and retains one copy of the letter of authorization. In cases of documented emergencies, authorization may be requested after the service has been provided. All other requirements of this subsection must be met.006.09INFERTILITY. The Department limits coverage for infertility to diagnosis and treatment of medical conditions when infertility is a symptom of a suspected medical problem. Reimbursement or coverage is not available when the sole purpose of the service is achieving a pregnancy.006.10LABOR AND DELIVERY. The Department covers reasonable and necessary services associated with pregnancy. Medical care for pregnancy is reimbursable, beginning with diagnosis of the condition, continuing through delivery, and ending after the necessary postnatal care, or termination of pregnancy. Postpartum services are covered for a 60-day period beginning on the day the pregnancy ends, and any remaining days in the month in which the 60th day falls, for women who were eligible for, applied for, and received medical assistance on the day the pregnancy ends. After the infant is delivered, the infant is treated as a separate patient for reimbursement purposes. 006.10(A)PHYSICIANS' SERVICES. The Department covers routine prenatal care, delivery, six weeks post-partum care, and routine urinalysis as a package service for physicians in accordance with 471 NAC 18. The Department does not reimburse hospitals for any physicians' services included in the package service.006.10(B)EXCEPTIONS. The Department may make exceptions to cover hospital outpatient or emergency room services which meet the coverage criteria for medically necessary services which are not included in the physicians' package service.006.10(C)INPATIENT. If the patient is admitted as an inpatient, and not released the same day, the services are considered inpatient services. If the patient is not admitted as an inpatient, the services are considered outpatient services.006.11ALCOHOL AND CHEMICAL DETOXIFICATION. The Department limits payment for alcohol and chemical detoxification to medically necessary treatment, subject to the Department's utilization review. This period includes an average detoxification period of two to three days with an occasional need for up to five days when the patient's condition dictates. A detoxification program for a particular patient may exceed five days and be covered if determined medically necessary by the Department. The Department does not cover services when the detoxification needs of an individual no longer require an inpatient hospital setting.006.12OSTEOGENIC STIMULATION. Electrical stimulation to augment bone repair (osteogenic stimulation) can be performed either invasively or non-invasively. 006.12(A)INVASIVE OSTEOGENIC STIMULATION. Invasive devices provide electrical stimulation directly at the fracture site either through percutaneously placed cathodes or by implantation of a coiled cathode wire into the fracture site. For percutaneously-placed cathodes, the power supply is externally placed and the leads connected to the inserted cathodes. For the implanted cathode, the power pack is implanted into soft tissue near the fracture site and subcutaneously connected to the cathode, creating a self-contained system with no external components. The Department covers use of the invasive device only for non-union of long bone fractures. The Department considers non-union to exist only after six months or more have elapsed without the fracture healing.006.12(B)NON-INVASIVE OSTEOGENIC STIMULATION. For the non-invasive device, opposing pads wired to an external power supply are placed over the cast. An electromagnetic field is created between the pads at the fracture site. The Department covers use of the non-invasive device only for: (i) Non-union of long bone fractures;(iii) Congenital pseudarthrosis.006.13BIOFEEDBACK THERAPY. Biofeedback therapy provides visual, auditory or other evidence of the status of certain body functions so that a person can exert voluntary control over the functions, and thereby alleviate an abnormal bodily condition. Biofeedback therapy often uses electrical devices to transform bodily signals indicative of such functions as heart rate, blood pressure, skin temperature, salivation, peripheral vasomotor activity, and gross muscle tone into a tone or light, the loudness or brightness of which shows the extent of activity in the function being measured. Biofeedback therapy differs from electromyography, which is a diagnostic procedure used to record and study the electrical properties of skeletal muscle. However, an electromyography device may be used to provide feedback with certain types of biofeedback. Biofeedback therapy is covered by the Department only when it is reasonable and necessary for the individual patient for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, and more conventional treatments have not been successful. This therapy is not covered for treatment of ordinary muscle tension states, for psychosomatic conditions, or for psychiatric conditions.006.14DIAGNOSTIC SERVICES. All reasonable and necessary diagnostic tests given for narcolepsy and sleep apnea are covered when the following criteria are met: (i) The clinic must be affiliated with a hospital;(ii) Patients must be referred to the sleep disorder clinic by a physician. The clinic must maintain a record of the attending physician's orders with signatures; and(iii) The need for diagnostic testing must be confirmed by medical evidence, e.g., physician examinations and laboratory tests. 006.14(A) Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the results are still pertinent is not covered. Most patients who undergo the diagnostic testing are not considered inpatients, although they may come to the facility in the evening for testing and then leave after their tests are over. The overnight stay is considered an integral part of these tests.006.15THERAPEUTIC SERVICES. The Department may cover therapeutic services provided they are standard and accepted services, and are reasonable and medically necessary for the patient. Sleep disorder clinics must provide therapeutic services in the hospital outpatient setting. Therapeutic services will be provided for: (A) Insomnia that is not associated with psychiatric disorders;(E) Shift work and schedule disturbances;(F) Restless leg syndrome;(I) Night terrors or dream anxiety attacks;006.16CARDIAC STRESS TESTING AND HOSPITAL OUTPATIENT CARDIAC REHABILITATION PROGRAMS. Stress testing is a covered diagnostic procedure for evaluating chest pain and as a component in the development of rehabilitation exercise prescriptions for the treatment of patients with known cardiac disease provided that during the testing: (i) A physician is present;(ii) Emergency equipment is available; and(iii) A standard emergency procedure plan is in effect. 006.16(A)STRESS TESTING. The use of stress testing in the absence of any specific diagnostic or therapeutic purpose is not covered as reasonable and necessary to the treatment of the patient's condition.006.16(B)OUTPATIENT. Outpatient cardiac rehabilitation programs consisting of individually prescribed physical exercise or conditioning and concurrent telemetric monitoring. When a program is provided by a hospital to its outpatients, the service is covered as an outpatient service. 006.16(B)(i)CARDIAC REHABILITATION EXERCISE PROGRAM. Hospital outpatient services in connection with a cardiac rehabilitation exercise program are considered reasonable and necessary only during that period of time when the patient's condition is such that the exercises can only be carried out safely under the direct, continuing supervision of a physician, and in a hospital environment. The monitoring required in these programs must be carried out by a hospital-employed nurse trained in cardiac rehabilitation with a physician overseeing the monitoring. Although on occasion physical therapists or occupational therapists are involved in these programs, they generally act only as exercise leaders. These services do not constitute covered physical therapy or occupational therapy. Since the type of cardiac rehabilitation exercise program which can be covered requires a hospital setting, this program is not covered in a skilled nursing facility.006.16(B)(ii)COVERAGE LIMIT. Coverage is limited to 12 weeks (or 36 sessions) of a monitored exercise program. For coverage beyond a maximum duration of 12 weeks (or 36 sessions), the provider must submit documentation supporting the patient's need for additional services. Documentation must include: (1) Progress report and exercise sessions;(5) Other medical problems;(9) Sources of stress, and support system; and006.17MEDICAL TRANSPLANTS. The Department covers transplants including donor services that are medically necessary and defined as non-experimental by Medicare. If no Medicare policy exists for a specific type of transplant, the Department will determine whether the transplant is medically necessary or non-experimental. The Department will cover transplantation services when performed in a facility approved by Centers for Medicaid and Medicare as meeting coverage criteria. 006.17(A)PRIOR AUTHORIZATION. The Department requires prior authorization of all transplant services or related donor service before the services are provided. An exception may be made for emergency situations, in which case verbal approval is obtained by the Department and the notification of authorization is sent later. This request for authorization must be submitted in writing or using the standard electronic Health Care Services Review: Request for Review and Response transaction (ASC X12N 278) by the physician to the Department. The Prior Authorization request must include at a minimum: (i) The patient's name, age, diagnosis, pertinent past medical history and treatment to this point, prognosis with and without the transplant, and the procedure(s) for which the authorization is requested;(ii) The patient's Nebraska Medicaid number;(iii) Name of hospital, city, and state where the service(s) will be performed;(iv) Name of physician(s) who will perform the surgery, if other than physician requesting authorization; and (1) If authorization is requested for a liver or heart transplant, in addition to the above information, two physicians must also supply the following statement: Recommending the transplant; and(2) Certifying and explaining why a transplant is medically necessary as the only clinical, practical, and viable alternative to prolong the client's life in a meaningful, qualitative way and at a reasonable level of functioning.006.17(B)SERVICES FOR A NEBRASKA MEDICAID-ELIGIBLE DONOR. The Department covers medically necessary services, including laboratory tests directly related to the transplant, for the Nebraska Medicaid-eligible donor to a Nebraska Medicaid-eligible client. The services must be directly related to the transplant.006.17(C)SERVICES FOR A NEBRASKA MEDICAID-INELIGIBLE DONOR. The Department covers medically necessary services, including laboratory tests directly related to the transplant, for the Nebraska Medicaid-ineligible donor to a Nebraska Medicaid-eligible client. The services must be directly related to the transplant and must directly benefit the Nebraska Medicaid transplant client. Coverage of treatment for complications related to the donor is limited to those that are reasonably medically foreseeable. Claims must be submitted under the Nebraska Medicaid-eligible client's case number.006.17(D) The Department reserves the right to request any medical documentation from the patient's record to support and substantiate claims submitted for payment.006.17(E) The Department is the payor of last resort.006.17(F)HOSPITAL INPATIENT SERVICES. Procurement costs include removal of organ, transportation, and associated costs. These costs must be billed by the transplanting hospital on the appropriate claim form or electronic format and separately identified on the Medicare cost report. The hospital must submit copies of the actual invoices for procurement costs, including transportation costs, on the appropriate claim form or electronic format.006.17(G) AMBULATORY ROOM AND BOARD. The Department may cover ambulatory room and board services for transplant patients and an attendant if necessary.006.18PHYSICIAN SERVICES. Surgeon(s) services will be paid according to the Nebraska Medicaid Practitioner Fee Schedule. This fee will include two weeks' routine post-operative care by the designated primary surgeon. Payment for routine post-operative care will not be made to other members of the surgical team. Physician services must be billed on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837).006.19ITINERANT PHYSICIAN VISITS. The Department covers non-emergency physician visits provided in a hospital outpatient setting if the services are: (i) Provided by an out-of-town specialist who has a contractual agreement with the hospital. The Department does not consider general practitioners or family practitioners to be specialists; and(ii) Determined to have been provided in the most appropriate place of service. 006.19(A) The hospital room charge is considered the technical component of the visit and must be billed on Form CMS-1450 (UB-92).006.20INFANT APNEA MONITORS. The Department covers rental of home infant apnea monitors for infants with medical conditions that require monitoring due to a specific medical diagnosis only if prescribed by and used under the supervision of a physician. Proper infant evaluation by the physician and parent/caregiver training must occur before placement of infant apnea monitor. Parent/caregiver training is not reimbursed as a service separate from infant apnea monitor rental. 006.20(A)MEDICAL GUIDELINES FOR THE PLACEMENT OF HOME INFANT APNEA MONITORS. The Department covers home infant apnea monitoring services for infants, defined as birth through completion of one year of age, who meet one of the following criteria: (i) Infants with one or more apparent life-threatening events (ALTE) requiring mouth-to-mouth resuscitation or vigorous stimulation. An apparent life-threatening event (ALTE) is defined as an episode that is frightening to the observer and characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually limpness), choking, or gagging. In some cases, the observer fears the infant has died;(ii) Symptomatic preterm infants;(iii) Siblings of one or more SIDS victims; or(iv) Infants with certain diseases or conditions, such as central hypoventilation, bronchopulmonary dysplasia, infants with tracheostomies, infants of substanceabusing mothers, or infants with less severe apparent life-threatening events (ALTE).006.20(B)APPROVAL OF HOME INFANT APNEA MONITOR SERVICE PROVIDERS. The Department covers rental of home infant apnea monitors and related supplies provided only by approved providers. To ensure all home apnea monitoring needs of infants are met, the Department requires the development of a home infant apnea monitor coordination plan. The coordination plan is not an individual patient plan; it is an overall program outline for the delivery of home apnea monitoring services.006.20(C)DOCUMENTATION REQUIRED AFTER INITIAL RENTAL PERIOD. Monitor rental exceeding the first two-month prescription period requires that an updated physician's narrative report of patient progress and a statement of continued need accompany the claim. A new progress report is required every two months. The report must include: (i) The number of apnea episodes during the previous prescription period;(ii) The results of any tests performed during the previous prescription period;(iii) Additional length of time needed; and(iv) Any additional information the physician may wish to provide.006.20(D)REMOVING THE INFANT FROM THE MONITOR. Criteria for removing infants from home infant apnea monitoring must be based on the infant's clinical condition. A monitor may be discontinued when apparent life-threatening event (ALTE) infants have had two periods, each of three months duration, free of significant alarms or apnea where vigorous stimulation or resuscitation was not needed. Evaluating the infant's ability to tolerate stress during this time is advisable. The provider must state the date of removal of the infant monitor on or in the final claim.006.20(E)COVERED AND NON-COVERED COMPONENTS. The Department does not cover monitors that do not use rechargeable batteries. The Department does not make separate payment for remote alarms. If provided, payment for a remote alarm is included in the monitor rental. Apnea monitor belts, lead wires, and reusable electrodes are covered for rented apnea monitors.006.20(F)PNEUMOCARDIOGRAMS. Pneumocardiograms are covered for diagnostic or evaluation purposes and when required to determine when the infant may be removed from the monitor. Payment does not include analysis and interpretation.006.20(G)BILLING. The hospital must bill for the technical component of infant apnea monitor services on the appropriate claim form or electronic format. The provider of the apnea monitor must state the date of removal of the infant monitor on the claim. Physicians' services must be billed as professional services on a CMS-1500 Form or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837).
006.21HOME PHOTOTHERAPY. The Department covers rental of home phototherapy (bilirubin) equipment for infants that require phototherapy when neonatal hyperbilirubinemia is the infant's sole clinical problem when prescribed by and used under the supervision of a physician. To ensure that home phototherapy needs of infants are met, the Department requires the development of a coordination plan. The coordination plan is not an individual patient plan; it is an overall program outline for the delivery of home phototherapy services. 006.21(A)APPROVAL OF HOME PHOTOTHERAPY PROVIDERS. The Department covers rental of home phototherapy equipment provided by approved providers. Physicians will not be approved as home phototherapy providers. 006.21(A)(i) The following conditions must be met prior to initiation of home phototherapy: (a) History and physical assessment by the infant's attending physician has occurred. If home phototherapy begins immediately upon discharge from the hospital, the newborn discharge exam will suffice;(b) Required laboratory studies have been performed, including, complete blood count (CBC), blood type on mother and infant, direct Coombs, direct and indirect bilirubin;(c) The physician certifies that the parent or caregiver is capable of administering home phototherapy;(d) Parent or caregiver have successfully completed training on use of the equipment; and(e) Equipment must be delivered and set up within 4 hours of discharge from the hospital or notification of provider, whichever is more appropriate. There must be a 24-hour per day repair or replacement service available.006.21(A)(ii) At a minimum, one bilirubin level must be obtained daily while the infant is receiving home phototherapy.006.21(B)LIMITATIONS ON COVERAGE OF HOME PHOTOTHERAPY SERVICES. Services will be reimbursed on a daily basis. The Department's daily allowable fee includes: (i) Phototherapy unit and all supplies, accessories, and services necessary for proper functioning and effective use of the therapy;(ii) A minimum of one daily visit to the home by a licensed or certified "health care professional" as identified by the supplier in the "Coordination Plan." The daily visits must include:(1) A brief home assessment; and(2) Collection and delivery of blood specimens for bilirubin testing when ordered by the physician to be collected in the home. The physician must be informed by the provider that this service is available. An outside agency or laboratory with whom the provider contracts for collection and delivery of blood specimens may not bill the Department directly since payment is included in the daily rental payment. Daily home visits must occur for home assessment even if the blood collection is done outside the home.(iii) Complete caregiver training on use of equipment and completion of necessary records.006.21(C)DISCONTINUING HOME PHOTOTHERAPY. Home phototherapy services will not be covered if the bilirubin level is less than 12 mgs at 72 hours of age or older.006.21(D)DOCUMENTATION. A physician's narrative report outlining the client's progress and the circumstances necessitating extended therapy must be submitted with the claim when billing for home phototherapy exceeding three days.006.21(E)PAYMENT. Payment for home phototherapy services does not include physician's professional services or laboratory and radiology services related to home phototherapy. These services must be billed by the physician or laboratory performing the service. The Department daily rental payment includes: (i) Phototherapy unit and all supplies, accessories, and services necessary for proper functioning and effective use of the therapy;(ii) A minimum of one daily visit to the home by a licensed or certified "health care professional" is required. The daily visits must include: (1) A brief home assessment; and(2) Collection and delivery of blood specimens for bilirubin testing when ordered by the physician to be collected in the home. The physician must be informed by the provider that this service is available. An outside agency or laboratory with whom the provider contracts for collection and delivery of blood specimens may not bill Medicaid directly since payment is included in the daily rental payment. Daily home visits must occur for home assessment even if the blood collection is done outside the home.(iii) Complete caregiver training on use of equipment and completion of necessary records.006.21(F)BILLING REQUIREMENTS. The provider must bill for home phototherapy daily rental on a single claim and indicate the total number of rental days as the units of service using the appropriate claim form or electronic format as outpatient services.006.22COORDINATION PLAN REQUIREMENT FOR CERTAIN SERVICES. Providers of apnea monitoring services and phototherapy services must maintain, as a part of the provider's records, a coordination plan, which must include: (1) An overview of the services provided, including the provider's charge for the services;(2) Descriptions and literature on the equipment and all supplies and accessories provided;(3) Copies of all forms, instructions, and record sheets for client use;(4) An outline of the training format used to train the client on use of equipment and other training requirements;(5) The type and frequency of client contact and identification and qualifications of personnel conducting client contacts; and(6) A statement of the provider's policy on equipment set-up, servicing, and availability for consultation on equipment problems. 006.22(A)The provider must notify the Department of any changes in the coordination plan. After review of the coordination plan, the provider may be required to amend the coordination plan.006.22(B)APPROPRIATE HOSPITAL SERVICES. Appropriate home infant apnea monitor services provided by a hospital with an approved infant apnea monitor coordination plan includes rental of the apnea monitor, trend event recorder, and ECG/respirator recorder; purchase of related supplies; conversion of cassette recording to tape for interpretation; and CO2/hypoxia studies.006.23AMBULATORY ROOM AND BOARD. The Department covers ambulatory room and board as a related transportation and as follows: 006.23(A)APPROVAL AS AN AMBULATORY ROOM AND BOARD PROVIDER. The Department approves only hospitals as ambulatory room and board providers. To receive the Department payment, each hospital providing ambulatory room and board services must be enrolled with the Department as a provider for hospital services. 006.23(A)(i)PROVIDER RE-APPROVAL. Each hospital approved by the Department to provide ambulatory room and board services must seek re-approval of its ambulatory room and board services from the Department when any of the following occur: (1) The charge to the Department for ambulatory room and board services changes;(2) There is a change in the physical location of the ambulatory room and board facility or the distance from the hospital building;(3) There is a change in the services the hospital is able to provide to clients in the ambulatory room and board facility; or(4) Other substantial changes are made to the hospital's ambulatory room and board services.006.23(B)GUIDELINES. The Department covers ambulatory room and board services as follows: (1) Ambulatory room and board services must be necessary to secure Nebraska Medicaid coverable services, including medical examinations or treatment.(2) The Department covers meals when receipt of Nebraska Medicaid coverable services requires the client to be away from their home for 12 hours or longer;(3) The Department covers lodging when an out-of-town overnight stay is necessary while receiving Nebraska Medicaid coverable services or if coverage of ambulatory room and board services will prevent a hospital inpatient stay; and(4) The Department covers meals and lodging for up to one day before or after receiving services if extensive travel is necessary.(5) The Department covers up to one person who accompanies the client when the client is physically or mental unable to travel or wait alone. For example, a child's parent or guardian. 006.23(B)(i) Payment for ambulatory room and board services outside these guidelines must be approved by the Department staff.006.23(C)DOCUMENTATION. The hospital must include a statement that documents the necessity for ambulatory room and board services for a client or for a client and an attendant on the hospital claim.006.23(D)BILLING AND PAYMENT. The hospital must bill for ambulatory room and board services provided by a Department-enrolled hospital as an outpatient service on the appropriate claim form or electronic format and the appropriate Healthcare Common Procedure Coding System procedure codes. Payment will be made using a hospitalspecific rate. Payment to the hospital must not exceed its charge for services provided to the general public.471 Neb. Admin. Code, ch. 10, § 006
Adopted effective 11/9/2020Amended effective 6/6/2022