471 Neb. Admin. Code, ch. 18, § 008

Current through September 17, 2024

Section 471-18-008 - PAYMENT

008.01GENERAL PAYMENT REQUIREMENTS. Nebraska Medicaid will reimburse the Provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter, the individual payment regulations in this chapter will govern.

008.02SPECIFIC PAYMENT REQUIREMENTS.

008.02(A)REIMBURSEMENT. Nebraska Medicaid pays for covered physician services, except clinical laboratory services, at the lower of the provider's submitted charge or the allowable amount for the procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for the date of service.

008.02(A)(i)EXCEPTION. The Department may enter into an agreement with an out-of-state provider for a rate which exceeds the rate according to the Nebraska Medicaid Practitioner Fee Schedule only when the Department has determined the individual requires specialized services which are not available in Nebraska and no other source of the specialized service can be found.

008.02(B)SITE OF SERVICE ADJUSTMENT. Nebraska Medicaid applies a site of service differential which reduces the fee schedule amount for specific Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes when the service is provided in a facility setting. Based on the Medicare differential, the Department will reimburse specific Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes with adjusted rates based on the site of service.

008.02(C)NON-PAYMENT OF OTHER PROVIDER PREVENTABLE CONDITIONS (OPPC). For physician and non-physician provider claims, payment will be denied for the following Other Provider Preventable Conditions (OPPCs):

(i) Wrong surgical or other invasive procedure performed on an individual;

(ii) Wrong surgical or other invasive procedure performed on the wrong body part; and

(iii) Wrong surgical or other invasive procedure performed on the wrong individual.

008.02(D)SURGERY. The surgical procedure, including 14 days post-operative care, is reimbursed under a Healthcare Common Procedure Coding System (HCPCS) surgery procedure code. When multiple surgical procedures are done at one time, the Department reimburses the primary procedure according to the Nebraska Medicaid Practitioner Fee Schedule. Any secondary procedures which add significant time and complexity to patient care is reimbursed at one-half of the amount which would be paid if the procedure were the primary procedure.

008.02(D)(i)ASSISTANT SURGEON. When an assistant surgeon is required, reimbursement is made according to the Nebraska Medicaid Practitioner Fee Schedule.

008.02(E)PRACTITIONER ADMINISTERED MEDICATIONS. The Department will reimburse practitioner administered injectable medications at 100 percent of the Medicare Drug Fee Schedule plus an administration fee as listed. Injectable medications approved by the Department but not included on the Medicare Drug Fee Schedule will be reimbursed at the wholesale acquisition cost (WAC) plus 6.8 percent.

008.02(E)(i)ALLERGY INJECTIONS. When the cost of the medication is not listed in either the Drug Topics Red Book or The Blue Book, allergy injections are paid at the provider's submitted charge up to the maximum allowable dollar amount under the Nebraska Medicaid Practitioner Fee Schedule per injection which includes medication and injection fee. If the allergy medication is not prepared in the office of the physician administering the allergen and the administering physician incurs no expense for the supply or the supplier bills the Department separately, the Department reimburses the administering physician according to the Medicaid Practitioner Fee Schedule for the injection fee. If the administering physician purchases the supply for administration in the office, the administering physician must not bill the Department for more than the cost of the supply. The Department must not exceed the maximum allowable dollar amount under the Nebraska Medicaid Practitioner Fee Schedule in reimbursement per allergy injection, which includes the cost of the medication and the injection fee.

008.02(E)(ii)IMMUNIZATIONS. The Department reimbursement is available for the provider's private stock vaccine and the administration fee for immunizations of adolescents age 19 and 20.

008.02(F)LABORATORY AND PATHOLOGY.

008.02(F)(i)PHYSICIAN'S OFFICE OR INDEPENDENT LABORATORY. Payment is based on the Nebraska Medicaid fee schedule for clinical laboratory services to cover the total service, both professional and technical components.

008.02(F)(i)(1)PHYSICIAN'S OFFICE LABORATORY. Payment for tests obtained in the physician's office but sent to an independent clinical laboratory or hospital for processing must be claimed by the facility performing the tests, using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code. The private physician's office may be reimbursed for the collection by venipuncture or catheterization for these procedures by using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code at the providers' submitted charge up to 100 percent of the Medicare clinical laboratory fee schedule. The Department does not reimburse the private physician for processing or interpreting tests performed outside their office.

008.02(F)(ii)CLINICAL LABORATORY SERVICES. Payment for clinical laboratory services including collection of laboratory specimens by venipuncture or catheterization is made at the amount allowed for each procedure code in the national fee schedule for clinical laboratory services as established by Medicare.

008.02(F)(ii)(1)LICENSED AND CERTIFIED INDEPENDENT CLINICAL LABORATORY. When a physician's private office sends the specimen to an independent clinical laboratory for processing, the Department pays for the procedure directly to the independent clinical laboratory. The Department does not reimburse the laboratory for collecting, handling, or drawing the specimen sent in by a physician's office. The Department pays for specimens collected by venipuncture or catheterization obtained by the hospital or independent laboratory for hospital or independent laboratory patients. The Department does not reimburse the private physician for processing or interpreting tests performed outside their office. The Department does not allow reimbursement for collection of specimens in a nursing home or long-term care facility. If a physician performs some tests on a specimen and then sends the same specimen to an outside facility for additional procedures, the private physician may be reimbursed for the medically necessary procedures performed in their office plus a fee for drawing the specimen by venipuncture or obtaining urine by catheterization sent to a hospital or independent laboratory.

008.02(F)(ii)(2)HOSPITAL CLINICAL LABORATORY SERVICES. Payment is made to the hospital as follows. There is no separate payment made to the pathologist for routine clinical laboratory services. To be paid, the pathologist must negotiate with the hospital to arrange a salary or compensation agreement.

(a)INPATIENT SERVICES. Payment is included in hospital's prospective payment rate in accordance with 471 NAC 10;

(b)OUTPATIENT SERVICES. Payment is made according to the fee schedule determined by the Department; and

(c)NON-PATIENT SERVICES. Payment is made according to the fee schedule determined by the Department.

008.02(G)PROFESSIONAL COMPONENT OF HOSPITAL DIAGNOSTIC AND THERAPEUTIC SERVICES. The Department pays for the professional component of a physician's hospital diagnostic or therapeutic service as described previously. Payment for the professional component of a radiology service provided in a hospital is made according to the Nebraska Medicaid Practitioner Fee Schedule. In the absence of available payment data as described previously, the Department pays for the professional component at a percentage of the Department's allowable fee for the total procedure. The percentage is established by the Department.

008.02(H)ANESTHESIOLOGY SERVICES. The Department pays for covered anesthesiology services in accordance with the reimbursement rates previously described. The Department does not make additional reimbursement for emergency and risk factors.

008.02(H)(i)PAYMENT FOR CERTIFIED REGISTERED NURSE ANESTHETISTS SERVICES. These services are paid according to the Nebraska Medicaid Practitioner Fee Schedule.

008.02(I)PAYMENT FOR SERVICES PROVIDED BY PHYSICIAN ASSISTANTS. Payment to physician assistants is made to the physician provider group number with whom the physician assistant is enrolled. When payment is made to the physician group, the physician is responsible for payment to the physician assistant. The Department will not make payments to physician's assistants who are employed by a hospital.

008.02(J)PAYMENT FOR TRANSPLANT SERVICES. The provider must submit, at the request of the Department, any medical documentation from the individual's record to support and substantiate claims submitted to the Department for payment.

008.02(J)(i)HOSPITAL SERVICES. For information on payment of inpatient and outpatient hospital services in accordance with 471 NAC 10.

008.02(J)(ii)PHYSICIAN SERVICES. Surgeon 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 postoperative care will not be made to other members of the surgical team. Services provided after the two-week post-operative period may be billed on a fee-for-service basis.

008.02(K)ITINERANT PHYSICIAN VISITS. The physician will be paid at the rate for the appropriate level of office visit.

008.02(L)NURSE MIDWIFE SERVICES. Payment for nurse midwife services is made to the group with whom the nurse-midwife has a practice agreement.

008.02(M)COMPREHENSIVE INTERDISCIPLINARY TREATMENT FOR A SEVERE FEEDING DISORDER.

008.02(M)(i)PEDIATRIC FEEDING DISORDER CLINIC INTENSIVE DAY TREATMENT. Reimbursement for pediatric feeding disorder clinic intensive day treatment for medically necessary services will be a bundled rate based on the sum of the fee scheduled amounts for covered services provided by Nebraska Medicaid enrolled licensed practitioners.

008.02(M)(ii)PEDIATRIC FEEDING DISORDER CLINIC OUTPATIENT TREATMENT. Pediatric feeding disorder clinic outpatient treatment for medically necessary services is reimbursed at the appropriate fee schedule amount for a physician consultation for covered services provided by Nebraska Medicaid enrolled licensed practitioners.

471 Neb. Admin. Code, ch. 18, § 008

Amended effective 7/2/2017.

Amended effective 7/5/2022

Amended effective 7/10/2022

Amended effective 9/17/2024