reglab/statecodes huggingface dataset:
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › Section 16.03.09.004 - INCORPORATION BY REFERENCE

Current through August 31, 2023
The following are incorporated by reference in this chapter of
				rules: (3-17-22)
01.
American
			 Speech-Language-Hearing Association (ASHA): Medicaid Guidance for
			 Speech-Language Pathology Services
. The American Speech-Language-Hearing
			 Association (2004) Medicaid Guidance for Speech-Language Pathology Services:
			 Addressing the "Under the Direction of' Rule technical report is available on
			 the internet at:
https://www.asha.org/
. The report may also
			 be obtained at the ASHA National Office, 2200 Research Boulevard, Rockville, MD
			 20850-3289, telephone (301) 296-5700. (3-17-22)
02.
DSM-5-TR
. American
			 Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
			 Fifth Edition, Text Revision (DSM-5-TR) Arlington, VA, American Psychiatric
			 Association, 2022. A copy of the manual is available for public review at the
			 Department of Health and Welfare, 450 West State Street, Boise, Idaho, 83702.
			 (7-1-23)T
03.
Estimated
			 Useful Lives of Depreciable Hospital Assets, 2004 Revised Edition, Guidelines
			 Lives
.This document may be obtained from American Hospital Publishing,
			 Inc., 211 East Chicago Avenue, Chicago, IL, 60611. (3-17-22)
04.
Medicare Durable Medical Equipment
			 Medicare Administrative Contractor Jurisdiction D Supplier Manual 2016, As
			 Amended (CMS/Medicare DME Coverage Manual)
. Since the supplier manual is
			 amended on a quarterly basis by CMS, the current year's manual is being
			 incorporated by reference, as amended, to allow for the incorporation of the
			 most recent amendments to the manual. The full text of the CMS/Medicare DME
			 Coverage Manual is available via the Internet at
https://med.noridianmedicare.com/web/jddme/education/supplier-manual
.
			 (3-17-22)
05.
Provider
			 Reimbursement Manual (PRM)
. The Provider Reimbursement Manual (PRM),
			 Part I and Part II (CMS Publication 15-1 and 15-2), is available on the CMS
			 website at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals.html
.
			 (3-17-22)
06.
Travel Policy
			 and Procedures
. The text of "State Travel Policy and Procedures,"
			 Appendices A and B, January 17, 2023, is available at the Office of the State
			 Controller, 700 W. State St., 5th Fl., Box 83720, Boise, Idaho 83720-0011 or at
https://www.sco.idaho.gov/LivePages/state-travel-policy-and-procedures.aspx
.
			 (7-1-23)T
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › Section 16.03.09.008 - AUDIT, INVESTIGATION, AND ENFORCEMENT

Current through August 31, 2023
The Department may audit, investigate, and take enforcement
				action under IDAPA 16.05.07, "The Investigation and Enforcement of Fraud,
				Abuse, and Misconduct." (7-1-23)T
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › Section 16.03.09.010 - DEFINITIONS: A THROUGH H

Current through August 31, 2023
For the purposes of these rules, the following terms are used
				as defined below: (3-17-22)
01.
Abortion
. The medical procedure necessary for the termination of
			 pregnancy endangering the life of the woman, or the result of rape or incest,
			 or determined to be medically necessary in order to save the health of the
			 woman. (3-17-22)
02.
Amortization
. The systematic recognition of the declining utility
			 value of certain assets, usually not owned by the organization or intangible in
			 nature. (3-17-22)
03.
Ambulatory Surgical Center (ASC)
. Any distinct entity that
			 operates exclusively for the purpose of providing surgical services to patients
			 not requiring hospitalization, and which is certified by the U.S. Department of
			 Health and Human Services as an ASC. (3-17-22)
04.
Audit
. An examination of
			 provider records on the basis of which an opinion is expressed representing the
			 compliance of a provider's financial statements and records with Medicaid law,
			 regulations, and rules. (3-17-22)
05.
Auditor
. The individual or
			 entity designated by the Department to conduct the audit of a provider's
			 records. (3-17-22)
06.
Audit
			 Reports
. (3-17-22)
a. Draft Audit
			 Report. A preliminary report of the audit finding sent to the provider for the
			 provider's review and comments. (3-17-22)
b. Final Audit Report. A final written report
			 containing the results, findings, and recommendations, if any, from the audit
			 of the provider, as approved by the Department. (3-17-22)
c. Interim Final Audit Report. A written
			 report containing the results, findings, and recommendations, if any, from the
			 audit of the provider, sent to the Department by the auditor.
			 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › Section 16.03.09.012 - DEFINITIONS: P THROUGH Z

Current through August 31, 2023
01.
Participant
. A person eligible for and enrolled in the Idaho Medical
			 Assistance Program. (3-17-22)
02.
Patient
. The person undergoing treatment or receiving services
			 from a provider. (3-17-22)
03.
Pharmacist
. A person who meets all the applicable requirements to
			 practice as a licensed pharmacist according to state regulations where the
			 services are provided. (7-1-23)T
04.
Physician
. A person
			 possessing a Doctor of Medicine (MD) degree or a Doctor of Osteopathy (DO)
			 degree, and within the State or United States territory services are provided
			 is either licensed to practice medicine, is a resident enrolled in a
			 postgraduate medical training program, is a licensed international medical
			 graduate, or is a licensed bridge year physician. (7-1-23)T
05.
Physician Assistant (PA)
. A
			 person who meets all the applicable requirements to practice as a licensed PA
			 according to state regulations where the services are provided.
			 (7-1-23)T
06.
Plan of
			 Care
. A written description of medical, remedial, habilitative, or
			 rehabilitative services to be provided to a participant, developed by or under
			 the direction and written approval of a physician. Medications, services, and
			 treatments are identified specifically as to amount, type, and duration of
			 service. (7-1-23)T
07.
Prepaid Ambulatory Health Plan (PAHP)
. Under
			 42 CFR
			 438.2, an entity that provides medical
			 services to enrollees under contract with the Department on the basis of
			 prepaid capitation payments, or other arrangements that do not use State Plan
			 payment rates. The PAHP does not provide or arrange for, and is not responsible
			 for the provision of any inpatient hospital or institutional services for its
			 enrollees, and does not have a comprehensive risk contract. (7-1-23)T
08.
Private Rate
. Rate most
			 frequently charged to private patients for a service or item.
			 (3-17-22)
09.
Prosthetic
			 Device
. Replacement, corrective, or supportive devices prescribed by a
			 physician or other licensed practitioner of the healing arts profession within
			 the scope of their practice as defined by state law to: (3-17-22)
a. Artificially replace a missing portion of
			 the body; or (3-17-22)
b. Prevent
			 or correct physical deformities or malfunctions; or (3-17-22)
c. Support a weak or deformed portion of the
			 body. (3-17-22)
d. Computerized
			 communication devices are not included in this definition of a prosthetic
			 device. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › Section 16.03.09.013 - MEDICAL CARE ADVISORY COMMITTEE (MCAC)

Current through August 31, 2023
The Director of the Department will appoint a MCAC to advise on
				health and medical services. (7-1-23)T
01.
Membership
. The MCAC will
			 include the following: (7-1-23)T
a. Licensed
			 physicians and other health professionals familiar with the medical needs of
			 low-income individuals and the resources available and required for their care;
			 and (7-1-23)T
b. Members of
			 stakeholder organizations and Medicaid participants.
			 (7-1-23)T
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PARTICIPANT PROVISIONS › Section 16.03.09.100 - ELIGIBILITY FOR MEDICAL ASSISTANCE

Current through August 31, 2023
IDAPA 16.03.01, "Eligibility for Health Care Assistance for
				  Families and Children," and IDAPA 16.03.05, "Eligibility for Aid to the Aged,
				  Blind, and Disabled (AABD)," are applicable in determining eligibility for
				  medical assistance. (7-1-23)T
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PARTICIPANT PROVISIONS › Section 16.03.09.125 - MEDICAL ASSISTANCE PROCEDURES

Current through August 31, 2023
01.
Issuance
				of Identification Cards
. When a person is determined eligible for
				medical assistance, the Department will issue a Medicaid identification card to
				the participant. When requested, the Department will give providers of medical
				services eligibility information regarding participants so that services may be
				provided. (3-17-22)
02.
Identification Card Information
. An identification card will be issued
				to each participant and will contain the following information: (3-17-22)
a. The name of the participant to whom the
				card was issued; and (3-17-22)
b.
				The participant's Medicaid identification number; and (3-17-22)
c. The card number.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PARTICIPANT PROVISIONS › Section 16.03.09.150 - CHOICE OF PROVIDERS

Current through August 31, 2023
01.
Service
				Selection
. Each participant may obtain any services available from any
				participating institution, agency, pharmacy, or practitioner of their choice,
				unless enrolled in Healthy Connections or a Prepaid Ambulatory Health Plan
				(PAHP) that limits provider choice. This, however, does not prohibit the
				Department from establishing the fees that will be paid to providers for
				furnishing medical and remedial care available under the Medical Assistance
				Program, or from setting standards relating to the qualifications of providers
				of such care. (3-17-22)
02.
Lock-In Option
. (3-17-22)
a. The
				Department may implement a total or partial lock-in program for any participant
				found to be misusing the Medical Assistance Program according to provisions in
				Sections 910 through
				918 of these rules.
				(3-17-22)
b. In situations where
				the participant has been restricted to a participant lock-in program, that
				participant may choose the physician and pharmacy of their choice. The
				providers chosen by the lock-in participant will be identified in the
				Department's Eligibility Verification System (EVS). This information will be
				available to any Medicaid provider who accesses the EVS.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PARTICIPANT PROVISIONS › Section 16.03.09.160 - RESPONSIBILITY FOR KEEPING APPOINTMENTS

Current through August 31, 2023
The participant is solely responsible for making and keeping
				  an appointment with the provider. The Department will not reimburse providers
				  when participants do not attend scheduled appointments. Providers may not bill
				  participants for missed appointments. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PARTICIPANT PROVISIONS › Section 16.03.09.165 - COST-SHARING

Current through August 31, 2023
01.
Co-Payments
. When a
				participant accesses certain services inappropriately, the provider can require
				the participant to pay a co-payment as described in IDAPA 16.03.18, "Medicaid
				Cost-Sharing." (3-17-22)
02.
Premiums
. A participant can be required to share in the cost of basic
				plan benefits in the form of a premium as described in IDAPA 16.03.18,
				"Medicaid Cost-Sharing." (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PROVIDER PROVISIONS › Section 16.03.09.200 - PROVIDER APPLICATION PROCESS

Current through August 31, 2023
01.
Provider
				Application
. Providers who meet Medicaid enrollment requirements may
				apply for Idaho Medicaid provider status with the Department. All healthcare
				providers who are eligible for a National Provider Identifier (NPI) must apply
				using that identifying number. For providers not eligible for a NPI, the
				Department will assign a provider number upon approval of the application.
				(3-17-22)
02.
Screening
				Levels
. In accordance with
				42 CFR
				455.450, the Department will assign risk
				levels of "limited," "moderate," or "high" to defined groups of providers.
				These assignments and definitions will be published in the provider handbook.
				(3-17-22)
03.
Medicare
				Enrollment Requirement for Specified Providers
. The following providers
				must enroll as Medicare providers or demonstrate enrollment with another
				state's Medicaid agency prior to enrollment or revalidation as an Idaho
				Medicaid provider. (3-17-22)
a. Any providers
				classified in the "moderate" or "high" categorical risk level, as defined in
				the provider handbook. (3-17-22)
b.
				Any provider type classified as an institutional provider by Medicare.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PROVIDER PROVISIONS › Section 16.03.09.205 - AGREEMENTS WITH PROVIDERS

Current through August 31, 2023
01.
In
				General
. All individuals or organizations must enter into a written
				provider agreement accepted by the Department prior to receipt of any
				reimbursement for services. Agreements may contain any terms or conditions
				deemed appropriate by the Department. All provider agreements must be signed by
				the provider or by an owner or officer who has the legal authority to bind the
				provider in the agreement. (3-17-22)
02.
Federal Disclosure
				Requirements
. To comply with the disclosure requirements in
				42 CFR
				455, Subpart B, each provider, other than an
				individual practitioner or a group of practitioners, must disclose to the
				Department: (3-17-22)
a. The full name and
				address of each individual who has either direct or indirect ownership interest
				in the disclosing entity or in any subcontractor of five percent (5%) or more
				prior to entering into an agreement or at the time of survey and certification;
				and (3-17-22)
b. Whether any person
				named in the disclosure is related to another person named in the disclosure as
				a spouse, parent, or sibling. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PROVIDER PROVISIONS › Section 16.03.09.210 - CONDITIONS FOR PAYMENT

Current through August 31, 2023
01.
Participant Eligibility
. The Department will reimburse providers for
				medical care and services, regardless of the current eligibility status of the
				medical assistance participant in the month of payment, provided a complete and
				properly submitted claim for payment has been received and each of the
				following conditions are met: (3-17-22)
a. The
				participant was found eligible for medical assistance for the month, day, and
				year during which the medical care and services were rendered;
				(3-17-22)
b. The participant
				received such medical care and services no earlier than the third month before
				the month in which application was made on such participant's behalf;
				(7-1-23)T
c. The provider verified
				the participant's eligibility on the date the service was rendered and can
				provide proof of the eligibility verification; and (7-1-23)T
d. Not more than twelve (12) months have
				elapsed since the month of the latest participant services for which such
				payment is being made. Medicare cross-over claims are excluded from the twelve
				(12) month submittal limitation. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PROVIDER PROVISIONS › Section 16.03.09.215 - THIRD PARTY LIABILITY

Current through August 31, 2023
01.
Determining Liability of Third Parties
. The Department will take
				reasonable measures to determine any legal liability of third parties for
				medical care and services rendered to a participant. (3-17-22)
02.
Third Party Liability as a Current
				Resource
. The Department is to treat any third party liability as a
				current resource when such liability is found to exist and payment by the third
				party has been made or will be made within a reasonable time.
				(3-17-22)
03.
Withholding
				Payment
. The Department must not withhold payment on behalf of a
				participant because of the liability of a third party when such liability, or
				the amount thereof, cannot be currently established or is not currently
				available to pay the participant's medical expense. (3-17-22)
04.
Seeking Third Party
				Reimbursement
. The Department will seek reimbursement from a third party
				when the party's liability is established after reimbursement to the provider
				is made, and in any other case in which the liability of a third party existed,
				but was not treated as a current resource, with the exceptions provided in
				Subsection 215.05 of this rule. (3-17-22)
a. The Department will seek reimbursement
				from a participant when a participant's liability is established after
				reimbursement to the provider is made; and (3-17-22)
b. In any other situation in which the
				participant has received direct payment from any third party resource and has
				not forwarded the money to the Department for services or items received.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PROVIDER PROVISIONS › Section 16.03.09.225 - REPORTING TO THE INTERNAL REVENUE SERVICE (IRS)

Current through August 31, 2023
In accordance with
				  26 U.S.C
				  6041, the Department must provide annual
				  information returns to the IRS showing aggregate amounts paid to providers
				  identified by name, address, and social security number or employer
				  identification number. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PROVIDER PROVISIONS › Section 16.03.09.230 - GENERAL PAYMENT PROCEDURES

Current through August 31, 2023
01.
Provided
				Services
. (3-17-22)
a. Each participant
				may consult a participating physician or provider of their choice for care and
				receive covered services by presenting their identification card to the
				provider, subject to restrictions imposed by participation in Healthy
				Connections or enrollment in a PAHP. (7-1-23)T
b. The provider must obtain the required
				information by using the Medicaid number on the identification card from the
				Electronic Verification System (EVS) and transfer the required information onto
				the appropriate claim form. Where the EVS indicates that a participant is
				enrolled in Healthy Connections, the provider must comply with referral or
				follow-up communication requirements under Section
				210 of these rules.
				(7-1-23)T
c. Upon providing the
				care and services to a participant, the provider or their agent must submit a
				properly completed claim to the Department. (3-17-22)
d. The Department is to process each claim
				received and make payment directly to the provider. (3-17-22)
e. The Department will not supply claim
				forms. Forms needed to comply with the Department's unique billing requirements
				are included in the Idaho Medicaid Provider Handbook.
				(7-1-23)T
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PROVIDER PROVISIONS › Section 16.03.09.231 - HANDLING OF OVERPAYMENTS AND UNDERPAYMENTS FOR SPECIFIED PROVIDERS

Current through August 31, 2023
The provisions in Subsections
				  231.01 and
				  231.02 of this rule apply only
				  to hospitals, FQHCs, RHCs and Home Health providers. (3-17-22)
01.
Interest Charges on Overpayments
				and Underpayments
. The Medicaid program will charge interest on
				overpayments, and pay interest on underpayments, as follows: (3-17-22)
a. Interest After Sixty Days of Notice. If
				full repayment from the indebted party is not received within sixty (60) days
				after the provider has received the Department reimbursement notice, interest
				will accrue from the date of receipt of the Department reimbursement notice,
				and will be charged on the unpaid settlement balance for each thirty (30) day
				period that payment is delayed. Periods of less than thirty (30) days will be
				treated as a full thirty (30) day period, and the thirty (30) day interest
				charge will be applied to any unpaid balance. Each payment will be applied
				first to accrued interest, then to the principal. Interest accrued on
				overpayments and interest on funds borrowed by a provider to repay overpayments
				are not an allowable interest expense. (3-17-22)
b. Waiver of Interest Charges. When the
				Department determines an overpayment exists, it may waive interest charges if
				it determines that the administrative costs of collecting them exceed the
				charges. (3-17-22)
c. Rate of
				Interest. The interest rate on overpayments and underpayments will be the
				statutory rate as set forth in Section
				28-22-104(1),
				Idaho Code, compounded monthly. (3-17-22)
d. Retroactive Adjustment. The balance and
				interest will be retroactively adjusted to equal the amounts that would have
				been due based on any changes that occur as a result of the final determination
				in the administrative appeal and judicial appeal process. Interest penalties
				will only applied to unpaid amounts and will be subordinated to final interest
				determinations made in the judicial review process.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PROVIDER PROVISIONS › Section 16.03.09.235 - PATIENT "ADVANCE DIRECTIVES."

Current through August 31, 2023
01.
Provider
				Participation
. Hospitals, nursing facilities, providers of home health
				care services (home health agencies, federally qualified health clinics, rural
				health clinics), hospice providers, and personal care RN supervisors must:
				(7-1-23)T
a. Provide all adults receiving
				medical care written and oral information (the information provided must
				contain all material found in the Department's approved Advance Directive
				Registration Form) which defines their rights under state law to make decisions
				concerning their medical care. (7-1-23)T
i.
				The provider must explain that the participant has the right to make decisions
				regarding their medical care which includes the right to accept or refuse
				treatment. If the participant has any questions regarding treatment, the
				facility or agency will notify the physician of those concerns. Their physician
				can answer any questions they may have about the treatment. (3-17-22)
ii. The provider will inform the participant
				of their rights to formulate advance directives, such as "Living Will" or
				"Durable Power of Attorney For Healthcare," or both. (7-1-23)T
iii. The provider must comply with Subsection
				235.02 of this rule.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PROVIDER PROVISIONS › Section 16.03.09.245 - PROVIDERS OF SCHOOL-BASED SERVICES

Current through August 31, 2023
Only school districts and charter schools can be reimbursed
				  for the services described in Sections
				  850 through
				  856 of these rules.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL PROVIDER PROVISIONS › Section 16.03.09.250 - SELECTIVE CONTRACTING

Current through August 31, 2023
The Department may contract with a limited number of
				  providers of certain Medicaid products and services, including: dental
				  services, eyeglasses, transportation, and some medical supplies.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS FOR INSTITUTIONAL PROVIDERS › Section 16.03.09.300 - COST REPORTING

Current through August 31, 2023
The provider's Medicaid cost report must be filed using the
				  Department designated reporting forms, unless the Department has approved an
				  exception. The request to use alternate forms must be sent to the Department in
				  writing, with samples attached, a minimum of ninety (90) days prior to the due
				  date for the cost report. The request for approval of alternate forms cannot be
				  used as a reason for late filing. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS FOR INSTITUTIONAL PROVIDERS › Section 16.03.09.305 - REIMBURSEMENT SYSTEM AUDITS

Current through August 31, 2023
01.
Scope of
				Reimbursement System Audits
. The Department reserves the right to audit
				financial and other records of the provider, and, when warranted, the records
				of entities related to the provider. Audits consist of the following types of
				records: (3-17-22)
a. Cost verification of
				actual costs for providing goods and services; (3-17-22)
b. Evaluation of provider's compliance with
				the provider agreement, reporting form instructions, and any applicable law,
				rule, or regulation; (3-17-22)
c.
				Effectiveness of the service to achieve desired results or benefits; and
				(3-17-22)
d. Reimbursement rates or
				settlement calculated under this chapter. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS FOR INSTITUTIONAL PROVIDERS › Section 16.03.09.330 - PROVIDER'S RESPONSIBILITY TO MAINTAIN RECORDS

Current through August 31, 2023
The provider must maintain financial and other records in
				  sufficient detail to allow the Department to audit them as described in Section
				  305 of these rules.
				  (3-17-22)
01.
Expenditure
				Documentation
. Documentation of expenditures must include the amount,
				date, purpose, payee, and the invoice or other verifiable evidence supporting
				the expenditure. (3-17-22)
02.
Cost Allocation Process
. Costs such as depreciation or
				amortization of assets and indirect expenses are allocated to activities or
				functions based on the original identity of the costs. Documentation to support
				basis for allocation must be available for verification. The assets referred to
				in this Section of rule are economic resources of the provider recognized and
				measured in conformity with generally accepted accounting principles.
				(3-17-22)
03.
Revenue
				Documentation
. Documentation of revenues must include the amount, date,
				purpose, and source of the revenue. (3-17-22)
04.
Availability of Records
.
				Records must be available for and subject to audit by the auditor, with or
				without prior notice, during any working day between the hours of 8:00 a.m. and
				5:00 p.m. at the provider's principal place of business in the state of Idaho.
				(3-17-22)
a. The provider is given the
				opportunity to provide documentation before the interim final audit report is
				issued. (3-17-22)
b. The provider
				is not allowed to submit additional documentation in support of cost items
				after the issuance of the interim final audit report.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS FOR INSTITUTIONAL PROVIDERS › Section 16.03.09.340 - DRAFT AUDIT REPORT

Current through August 31, 2023
Following completion of the audit field work and before
				  issuing the interim final audit report to the Department, the auditor will
				  issue a draft audit report and forward a copy to the provider for review and
				  comment. (3-17-22)
01.
Review
				Period
. The provider will have a period of sixty (60) days, beginning on
				the date of transmittal, to review and provide additional comments or evidence
				pertaining to the draft audit report. The review period may be extended when
				the provider: (3-17-22)
a. Requests an
				extension prior to the expiration of the original review period; and
				(3-17-22)
b. Clearly demonstrates
				the need for additional time to properly respond. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS FOR INSTITUTIONAL PROVIDERS › Section 16.03.09.341 - FINAL AUDIT REPORT

Current through August 31, 2023
The auditor will incorporate the provider's response and an
				  analysis of the response into the interim final report as appendices and
				  transmit it to the Department. The Department will issue a final audit report
				  and a notice of program reimbursement, if applicable, that sets forth
				  settlement amounts due to the Department or the provider. The final audit
				  report and notice of program reimbursement, if applicable, will take into
				  account the findings made in the interim final audit report and the response of
				  the provider to the draft audit report (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS FOR INSTITUTIONAL PROVIDERS › Section 16.03.09.360 - RELATED PARTY TRANSACTIONS

Current through August 31, 2023
01.
Principle
. Costs applicable to services, facilities and supplies
				furnished to the provider by organizations or persons related to the provider
				by common ownership, control, etc., are allowable at the cost to the related
				party. Such costs are allowable to the extent that they relate to patient care,
				are reasonable, ordinary, and necessary, and are not in excess of those costs
				incurred by a prudent cost-conscious buyer. (3-17-22)
02.
Cost Allowability -
				Regulation
. Allowability of costs is subject to the regulations
				prescribing the treatment of specific items as outlined in
				42 CFR
				413.17, et al., and the Providers
				Reimbursement Manual, PRM Chapter 10 and other applicable chapters of the PRM.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS FOR INSTITUTIONAL PROVIDERS › Section 16.03.09.361 - APPLICATION

Current through August 31, 2023
01.
Determination of Common Ownership
				or Control in the Provider Organization and Supply Organization
. In
				determining whether a provider organization is related to a supplying
				organization, the tests of common ownership and control are to be applied
				separately. If the elements of common ownership or control are not present in
				both organizations, the organizations are deemed not to be related to each
				other. (3-17-22)
a. Common Ownership Rule. A
				determination as to whether an individual(s) possesses ownership or equity in
				the provider organization and the supplying organization, so that the
				organizations will be considered to be related by common ownership, will be
				made on the basis of the facts and circumstances in each case.
				(3-17-22)
b. Control Rule. The term
				"control" includes any kind of control whether or not it is legally enforceable
				and however it is exercisable or exercised. It is the reality of the control
				that is decisive, not its form or the mode of its exercise.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › GENERAL REIMBURSEMENT PROVISIONS FOR INSTITUTIONAL PROVIDERS › Section 16.03.09.362 - EXCEPTION TO THE RELATED ORGANIZATION PRINCIPLE

Current through August 31, 2023
An exception is provided to the general rule applicable to
				  related organizations. The exception applies if the provider demonstrates by
				  convincing evidence to the satisfaction of the intermediary: (3-17-22)
01.
Supplying Organization
. That
				the supplying organization is a bona fide separate organization;
				(3-17-22)
02.
Nonexclusive
				Relationship
. That a substantial part of the supplying organization's
				business activity of the type carried on with the provider is transacted with
				other organizations not related to the provider and the supplier by common
				ownership or control and there is an open, competitive market.
				(3-17-22)
03.
Lease or
				Rentals of Hospital
. The exception is not applicable to sales, lease or
				rentals of hospitals. These transactions would not meet the requirement that
				there be an open, competitive market for the facilities furnished as described
				in Sections 1008 and
				1012, PRM. (3-17-22)
a. Rentals. Rental expense for transactions
				between related entities will not be recognized. Costs of ownership will be
				allowed. (3-17-22)
b. Purchases.
				When a facility is purchased from a related entity, the purchaser's depreciable
				basis must not exceed the seller's net book value as described in Section
				1005, PRM.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › EXCLUDED SERVICES › Section 16.03.09.390 - SERVICES, TREATMENTS, AND PROCEDURES NOT COVERED BY MEDICAL ASSISTANCE

Current through August 31, 2023
The following services, treatments, and procedures are not
				  covered for payment by the Medical Assistance Program: (3-17-22)
01.
Service Categories Not
				Covered
. The following service categories are not covered for payment by
				the Medical Assistance Program: (3-17-22)
a.
				Acupuncture services; (3-17-22)
b.
				Naturopathic services; (3-17-22)
c.
				Bio-feedback therapy; (3-17-22)
d.
				Group hydrotherapy; and (3-17-22)
e. Fertility-related services, including
				testing. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › EXCLUDED SERVICES › Section 16.03.09.399 - COVERED SERVICES UNDER BASIC PLAN BENEFITS

Current through August 31, 2023
Individuals who are eligible for Medicaid Basic Plan Benefits
				  are eligible for the following benefits, subject to the coverage limitations
				  contained in these rules. Those individuals eligible for services under IDAPA
				  16.03.10, "Medicaid Enhanced Plan Benefits," are also eligible for the services
				  covered under this chapter of rules, unless specifically exempted.
				  (3-17-22)
01.
Hospital
				Services
. The range of hospital services covered is described in
				Sections 400 through
				449 of these rules. (3-17-22)
a. Inpatient and outpatient Hospital Services
				are described in Sections
				400 through
				416. (3-17-22)
b. Reconstructive Surgery services are
				described in Sections
				420 through
				426. (3-17-22)
c. Surgical procedures for weight loss are
				described in Sections
				430 through
				436. (3-17-22)
d. Investigational procedures or treatments
				are described in Sections
				440 through
				446. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: HOSPITAL SERVICES › Section 16.03.09.401 - HOSPITAL REIMBURSEMENT - PROSPECTIVE PAYMENT SYSTEMS

Current through August 31, 2023
Providers identified in Section
					 400.10.a. and 400.10.d will be
					 reimbursed for inpatient services using an All Patient Refined Diagnosis
					 Related Group (APR-DRG) as outlined in the Medicaid Provider Agreement
					 otherwise beginning with service periods on or after July 1, 2021.
					 (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: HOSPITAL SERVICES › Section 16.03.09.402 - INPATIENT HOSPITAL SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
The policy, rules, and regulations to be followed will be
					 those cited in 42 CFR
					 456.50 through
					 42 CFR
					 456.145. All hospital services must conform
					 to federal and state laws and regulations. Services must be medically necessary
					 as defined in Section
					 011 of these rules.
					 (3-17-22)
01.
Initial Length of
				  Stay
. Prior authorization requirement for an initial length of stay will
				  be established by the Department, or its designee, in the Idaho Medicaid
				  Provider Handbook for hospitals not reimbursed under DRG methodologies.
				  (3-17-22)
02.
Extended
				  Stay
. The Department, or its designee, will establish authorization
				  requirements in the Idaho Medicaid Provider Handbook for hospitals not
				  reimbursed under DRG methodologies. An authorization is necessary when the
				  appropriate care of the participant indicates the need for hospital days in
				  excess of the initial length of stay, or previously approved extended stay.
				  (3-17-22)
03.
Exceptions and
				  Limitations
. The following exceptions and limitations apply to
				  in-patient hospital services for hospitals not reimbursed under DRG
				  methodologies: (3-17-22)
a. Payment for
				  accommodations is limited to the hospital's all-inclusive rate. The
				  all-inclusive rate is a flat fee charge incurred on a daily basis that covers
				  both room and board. (3-17-22)
b.
				  The Department will not authorize reimbursement above the all-inclusive rate
				  unless the attending physician orders a room that is not an all-inclusive rate
				  room for the patient because of medical necessity.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: HOSPITAL SERVICES › Section 16.03.09.403 - INPATIENT HOSPITAL SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Prior Authorization
. Some
				  services may require a prior authorization from the Department or its designee.
				  Documentation for the request must include the most recent plan of care and
				  adequate documentation to demonstrate continued medical necessity. The
				  Department will set additional documentation requirements in the Idaho Medicaid
				  Provider Handbook to ensure quality of care and integrity of services.
				  (3-17-22)
02.
Certification
				  of Need
. At the time of admission, the physician must certify that
				  inpatient services are necessary. Recertification must occur at least every
				  sixty (60) days inpatient hospital services are required, but may be required
				  more frequently as determined by the Department. (3-17-22)
03.
Individual Plan of Care
. The
				  individual plan of care is a written plan developed for the participant upon
				  admission to a hospital and updated at least every sixty (60) days, but may be
				  required more frequently as determined by the Department. The plan must
				  include: (3-17-22)
a. Diagnoses, symptoms,
				  complaints, and complications indicating the need for admission;
				  (3-17-22)
b. A description of the
				  functional level of the individual; (3-17-22)
c. Any orders for medications, treatments,
				  rehabilitative services, activities, social services, or diet; and
				  (3-17-22)
d. Plans for continuing
				  care or discharge, as appropriate. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: HOSPITAL SERVICES › Section 16.03.09.404 - INPATIENT HOSPITAL SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
In addition to the provider enrollment agreement, each
					 claim submitted by a hospital constitutes an agreement by which the hospital
					 agrees to accept and abide by the Department's rules. Only a Medicare certified
					 hospital, licensed by the state in which it operates, may enroll in the Idaho
					 Medicaid program. Hospitals not participating as a Medicaid swing-bed provider,
					 which are licensed for long-term care or as a specialty hospital that provides
					 a nursing home level of care, will be reimbursed as a nursing facility.
					 Hospitals not eligible for enrollment which render emergency care will be paid
					 rates established in these rules. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: HOSPITAL SERVICES › Section 16.03.09.406 - INPATIENT HOSPITAL SERVICES: QUALITY ASSURANCE

Current through August 31, 2023
The designated QIO must prepare, distribute, and maintain a
					 provider manual that is periodically updated. The manual must include the
					 following: (3-17-22)
01.
QIO
				  Information
. The QIO's policies, criteria, standards, operating
				  procedures, and forms for performing: preadmission monitoring, assessment
				  reviews, continued stay requests, and requests for retroactive medical reviews.
				  (3-17-22)
02.
Department
				  Provisions
. Department-selected diagnoses and elective procedures in
				  which a hospital will request preauthorization of an admission, transfer, or
				  continuing stay. (3-17-22)
03.
Approval Timeframe
. A provision that the QIO will inform the
				  hospital of a certification within five (5) days, or other time frame as
				  determined by the Department, of an approved admission, transfer, or continuing
				  stay. (3-17-22)
04.
Method of
				  Notice
. The method of notice to hospitals of QIO denials for specific
				  admissions, transfers, continuing stays, or services rendered in post-payment
				  reviews. (3-17-22)
05.
Procedural Information
. The procedures that providers or participants
				  will use to obtain reconsideration of a denial by the QIO prior to appeal to
				  the Department. Such requests for reconsideration by the QIO must be made in
				  writing to the QIO within one hundred eighty (180) days of the issuance of the
				  "Notice of Non-Certification of Hospital Days." (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: HOSPITAL SERVICES › Section 16.03.09.410 - OUTPATIENT HOSPITAL SERVICES: DEFINITIONS

Current through August 31, 2023
Outpatient hospital services include preventive,
					 diagnostic, therapeutic, rehabilitative or palliative items, and services
					 furnished by or under the direction of a physician or dentist, unless excluded
					 by any other provisions of this chapter. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: HOSPITAL SERVICES › Section 16.03.09.412 - OUTPATIENT HOSPITAL SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Services Provided On-Site
.
				  Outpatient hospital services must be provided on-site. (3-17-22)
02.
Exceptions and Limitations
.
				  (3-17-22)
a. Payment for emergency room
				  service is limited to six (6) visits per calendar year. (3-17-22)
b. Emergency room services that are followed
				  immediately by admission to inpatient status will be excluded from the six (6)
				  visit limit. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: HOSPITAL SERVICES › Section 16.03.09.413 - OUTPATIENT HOSPITAL SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Review Prior to Delivery of
				  Outpatient Services
. Failure to obtain a timely review from the
				  Department or its quality improvement organization (QIO) prior to delivery of
				  outpatient services, listed on the select procedure and diagnosis list in the
				  QIO Idaho Medicaid Providers Manual and the Hospital Provider Handbook, as
				  amended, for participants who are eligible at the time of service, will result
				  in a retrospective review. The Department will assess a late review penalty, as
				  outlined in Subsection
				  405.02 of these rules, when a
				  review is conducted due to an untimely request. (3-17-22)
02.
Follow-Up for Emergency Room
				  Patients
. Hospitals must establish procedures to refer Medicaid
				  participants who are not enrolled in Healthy Connections to an Idaho Medicaid
				  Healthy Connections provider, if one is available within a reasonable distance
				  of the participant's residence. Hospitals must coordinate care of patients who
				  already have a Healthy Connections provider with that PCP. (3-17-22)