reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 15 - Health Services for American Indians › Chapter 201 - General Provisions › Section XV-20103 - Cancellation of Participation

Current through Register Vol. 50, No. 6, June 20, 2024
A. A
				  "638" facility's participation in the Medicaid Program may be cancelled if it
				  is determined that the facility is not providing care in compliance with
				  Medicaid regulations and/or state laws.
B. The Department of Health and Hospitals
				  may, at its discretion, cancel the participation of these facilities if:
1. it determines that the health care needs
				  of the Louisiana's American Indian population are not being met by the
				  facility; or
2. CMS discontinues
				  the terms of the Memorandum of Agreement with Indian Health Service which allow
				  states to claim 100 percent federal medical assistance percentage for payments
				  made by the state for services rendered to Medicaid eligible American Indians
				  through an IHS owned or leased facility or a tribal "638" facility.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 15 - Health Services for American Indians › Chapter 203 - Provider Participation › Section XV-20301 - "638" Facilities

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order
				  to participate in the Medicaid Program as a "638" facility, the facility must
				  provide health services and be operated by:
1. a federally recognized tribe that meets
				  the definition as set forth in
				  25 U.S.C. §
												1603 (d); or
2. a tribal organization as that term is
				  defined in 25 U.S.C. §
												450 b(
l
); or
3. an inter-tribal consortium as that term is
				  defined in 25 U.S.C. §
												458 aaa(a)(5).
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 15 - Health Services for American Indians › Chapter 205 - Recipient Eligibility › Section XV-20501 - Target Population

Current through Register Vol. 50, No. 6, June 20, 2024
A. A
				  recipient qualifies as a member of the target population if he/she meets the
				  definition of an Indian as set forth in
				  25 U.S.C. §
											1603 (c) or the definition
				  of a statutorily eligible individual as set forth in
				  25 U.S.C. §
											1680 c(a)(1) and (2).
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 15 - Health Services for American Indians › Chapter 207 - Covered Services › Section XV-20701 - Outpatient Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. A "638"
				  facility shall provide preventive, diagnostic, therapeutic, rehabilitative or
				  palliative services that are furnished to outpatients by or under the direction
				  of a:
1. physician;
2. dentist;
3. physician's assistant;
4. psychologist or licensed
				  counselor;
5. nurse practitioner,
				  nurse midwife or clinical nurse specialist;
6. x-ray technician; or
7. pharmacist.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 15 - Health Services for American Indians › Chapter 207 - Covered Services › Section XV-20703 - Service Limitations

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Consultations with more than one facility health professional on the same day
				  and at a single location constitute a single encounter. Services shall not be
				  arbitrarily delayed or split in order to bill additional encounters. A maximum
				  of one encounter per recipient per 24-hour period shall be
				  reimbursed.
AUTHORITY NOTE:
					 Promulgated in accordance with R.S. 36: 254 and Title XIX of the Social
					 Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 15 - Health Services for American Indians › Chapter 207 - Covered Services › Section XV-20705 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Reimbursement shall be the encounter rate established by the U.S. Department of
				  Health and Human Services, Indian Health Service for "638"
				  facilities.
B. Reimbursement for
				  prescribed drugs is included in the encounter rate when the prescription is
				  dispensed during the same time period as a visit with one or more facility
				  health professionals. Reimbursement for refilling a prescription shall be the
				  established encounter rate for the facility.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254, and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 17 - Family Planning Services › Chapter 251 - General Provisions › Section XV-25101 - Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. Effective July
				  1, 2014, the Medicaid Program shall provide coverage of family planning
				  services and supplies under the Medicaid state plan, to a new targeted group of
				  individuals who are otherwise ineligible for Medicaid. This new optional
				  coverage group may also include individuals receiving family planning services
				  through the section 1115 demonstration waiver, Take Charge Program, if it is
				  determined that they meet the eligibility requirements for the state plan
				  family planning services.
B. The
				  primary goals of family planning services are to:
1. increase access to services which will
				  allow improved reproductive and physical health;
2. improve perinatal outcomes; and
3. reduce the number of unintended
				  pregnancies.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 17 - Family Planning Services › Chapter 253 - Eligibility Criteria › Section XV-25301 - Recipient Qualifications

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Recipients who qualify for family planning services in the new categorically
				  needy group include individuals of child bearing age who meet the following
				  criteria:
1. women who are not pregnant and
				  have income at or below 138 percent of the federal poverty level; and
2. men who have income at or below 138
				  percent of the federal poverty level.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 17 - Family Planning Services › Chapter 255 - Services › Section XV-25501 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Medicaid
				  covered family planning services include:
1.
				  office visits and necessary re-visits for physical examinations as it relates
				  to family planning or family planning-related services;
2. contraceptive counseling (including
				  natural family planning), education, follow-ups and referrals;
3. laboratory examinations and tests for the
				  purposes of family planning and management of sexual health;
4. pharmaceutical supplies and devices to
				  prevent conception, including all methods of contraception approved by the
				  Federal Food and Drug Administration; and
5. male and female sterilization procedures
				  and follow-up tests provided in accordance with 42 CFR 441, subpart
				  F.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 17 - Family Planning Services › Chapter 255 - Services › Section XV-25503 - Service Delivery

Current through Register Vol. 50, No. 6, June 20, 2024
A. Family
				  planning services may be delivered through any enrolled Medicaid provider whose
				  scope of practice includes family planning services.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 17 - Family Planning Services › Chapter 257 - Reimbursement › Section XV-25701 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. All
				  Medicaid providers, including federally qualified health centers, rural health
				  clinics and tribal 638 facilities, shall be reimbursed according to the
				  established fee-for-service rates published in the Medicaid fee schedule for
				  family planning services.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 18 - Free-Standing Birthing Centers › Chapter 265 - General Provisions › Section XV-26501 - Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Medicaid
				  Program shall provide coverage and reimbursement for labor and delivery
				  services rendered by free-standing birthing centers (FSBCs). Stays for delivery
				  at the FSBC are typically less than 24 hours and the services rendered for
				  labor and delivery are very limited, or nonexistent, in comparison to delivery
				  services rendered during inpatient hospital stays.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254, and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 18 - Free-Standing Birthing Centers › Chapter 265 - General Provisions › Section XV-26503 - Definitions

Current through Register Vol. 50, No. 6, June 20, 2024
Birthing Center
a facility, for the primary
					 purpose of performing low-risk deliveries, that is not a hospital or licensed
					 as part of a hospital, where births are planned to occur away from the mothers
					 usual residence following a low-risk pregnancy.
Low-Risk Pregnancy
a normal, uncomplicated
					 prenatal course as determined by documentation of adequate prenatal care and
					 the anticipation of a normal, uncomplicated labor and birth, as defined by
					 reasonable and generally accepted criteria adopted by professional groups for
					 maternal, fetal, and neonatal health care.
Surrounding Hospital
a hospital located
					 within a 20-mile radius of the birthing center in urban areas and within a
					 30-mile radius of the birthing center in rural areas.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254, and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 18 - Free-Standing Birthing Centers › Chapter 267 - Services › Section XV-26701 - Scope of Services

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Free-standing birthing centers shall be reimbursed for labor and low-risk
				  delivery services provided to Medicaid eligible pregnant women by an
				  obstetrician, family practitioner, certified nurse midwife, or licensed
				  midwife. FSBC services are appropriate when a normal, uncomplicated labor and
				  birth is anticipated.
B. Services
				  shall be provided by the attending practitioner from the time of the pregnant
				  woman's admission through the birth and the immediate postpartum
				  period.
C. Service Limitation. FSBC
				  staff shall not administer general or epidural anesthesia services.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254, and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 18 - Free-Standing Birthing Centers › Chapter 269 - Provider Participation › Section XV-26901 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order
				  to enroll to participate in the Louisiana Medicaid Program as a provider of
				  labor and delivery services, the FSBC must:
1. be accredited by the Commission for
				  Accreditation of Birth Centers; and
2. be approved/certified by the Medicaid
				  medical director.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 18 - Free-Standing Birthing Centers › Chapter 269 - Provider Participation › Section XV-26903 - Staffing Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A. The FSBC
				  shall have on staff: 1. a licensed obstetrician, family practitioner, certified
				  nurse midwife, or licensed midwife who shall attend each woman in labor from
				  the time of admission through birth and the immediate postpartum period.
a. A licensed midwife providing birthing
				  services within the FSBC must:
i. have passed
				  the national certification exam through the North American Registry of
				  Midwives; and
ii. hold a current,
				  unrestricted state license with the Louisiana State Board of Medical
				  Examiners.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 18 - Free-Standing Birthing Centers › Chapter 271 - Reimbursement › Section XV-27101 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Effective for dates of service on or after November 20, 2015, a FSBC shall be
				  reimbursed a one-time payment for labor and delivery services at a rate equal
				  to 90 percent of the average per diem rates of surrounding hospitals providing
				  the same services.
1. Attending physicians
				  shall be reimbursed for birthing services according to the published fee
				  schedule rate for physician services rendered in the Professional Services
				  Program.
2. Certified nurse
				  midwives providing birthing services within a FSBC shall be reimbursed at 80
				  percent of the published fee schedule rate for physician services rendered in
				  the Professional Services Program.
3. Licensed midwives providing birthing
				  services within a FSBC shall be reimbursed at 75 percent of the published fee
				  schedule rate for physician services in the Professional Services
				  Program.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 19 - Pediatric Day Health Care Program › Chapter 275 - General Provisions › Section XV-27501 - Program Description and Purpose

Current through Register Vol. 50, No. 6, June 20, 2024
A. Pediatric Day Health Care (PDHC) Services
1. An array of services that are designed to
				  meet the medical, social and developmental needs of children up to the age of
				  21 who have a complex medical condition which requires skilled nursing care and
				  therapeutic interventions on an ongoing basis in order to:
a. preserve and maintain health
				  status;
b. prevent death;
c. treat/cure disease;
d. ameliorate disabilities or other adverse
				  health conditions; and/or
e.
				  prolong life.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 19 - Pediatric Day Health Care Program › Chapter 275 - General Provisions › Section XV-27503 - Recipient Criteria

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order to
				  qualify for PDHC services, a Medicaid recipient must meet the following
				  criteria. The recipient must:
1. be from birth
				  up to 21 years of age;
2. have a
				  medically complex condition which involves one or more physiological or organ
				  systems and requires skilled nursing and therapeutic interventions performed by
				  a knowledgeable and experienced licensed professional registered nurse (RN) or
				  licensed practical nurse (LPN) on an ongoing basis in order to:
a. preserve and maintain health
				  status;
b. prevent death;
c. treat/cure disease;
d. ameliorate disabilities or other adverse
				  health conditions; and/or
e.
				  prolong life;
3. have a
				  signed physicians order and plan of care, not to exceed 90 days, for pediatric
				  day health care by the recipients physician specifying the frequency and
				  duration of services; and
4. be
				  stable for outpatient medical services in a home or community-based setting.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 19 - Pediatric Day Health Care Program › Chapter 277 - Services › Section XV-27701 - Service Coverage and Limitations

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Medicaid Program will reimburse a
				  pediatric day health care facility for the following covered services:
1. nursing care;
2. respiratory care;
3. physical therapy;
4. speech-language therapy;
5. occupational therapy;
6. social services;
7. personal care services;
8. transportation to and from the PDHC
				  facility; and
9. one or more meals
				  and snacks per day depending on the child's length of stay.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 19 - Pediatric Day Health Care Program › Chapter 279 - Provider Participation › Section XV-27901 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. In order
				  to participate in the Medicaid Program, a facility must have a current, valid
				  PDHC facility license issued by the department. Each PDHC facility site shall
				  be separately enrolled in the Medicaid Program.
B. A parent, legal guardian or legally
				  responsible person providing care to a medically complex child in a home or any
				  other extended care or long-term care facility, is not considered to be a PDHC
				  facility and shall not be enrolled in the Medicaid Program as a PDHC services
				  provider.
C. All enrolled PDHC
				  services providers must comply with all of the licensing standards adopted for
				  pediatric day health care facilities.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XV - Services for Special Populations › Subpart 19 - Pediatric Day Health Care Program › Chapter 281 - Reimbursement Methodology › Section XV-28101 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Reimbursement for PDHC services shall be a statewide fixed per diem rate which
				  is based on the number of hours that a qualified recipient attends the PDHC
				  facility.
1. A full day of service is more
				  than six hours, not to exceed a maximum of 12 hours per day.
2. A partial day of service is six hours or
				  less per day.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XVII - Prosthetics and Orthotics › Subpart 1 - General Provisions › Chapter 1 - Prior Authorization › Section XVII-101 - Purchase and Repairs

Current through Register Vol. 50, No. 6, June 20, 2024
A. Prior
				  authorization is required before payment can be issued for the purchase or
				  repair of prosthetics and orthotics.
B. Prior authorization is performed by the
				  Medicaid fiscal intermediary under contractual arrangement with the Bureau of
				  Health Services Financing and is the responsibility of the Prior Authorization
				  Unit (PAU).
C. Every prior
				  authorization request shall contain:
1.
				  medical information from a physician, including:
a. a written prescription from a licensed
				  physician or a physician's order form signed by the prescribing
				  physician;
b. the diagnosis related
				  to the request; and
c. other
				  medical information to support the need for the requested item, including
				  documentation that the medical criteria specific to the requested items are
				  met;
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XVII - Prosthetics and Orthotics › Subpart 1 - General Provisions › Chapter 3 - Provider Participation › Section XVII-301 - Accreditation Requirements

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Effective for dates of service on or after January 1, 2009, all providers
				  seeking Medicaid reimbursement for prostheses, orthoses, prosthetic services
				  and orthotic services must be accredited by the American Board of Certification
				  in Orthotics, Prosthetics and Pedorthics, or by the Board of
				  Certification/Accreditation, International.
1. These accreditation provisions shall not
				  apply to a licensed optometrist or a licensed ophthalmologist, and shall not
				  prohibit a licensed occupational therapist or a licensed physical therapist
				  from practicing within his scope of practice.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XVII - Prosthetics and Orthotics › Subpart 1 - General Provisions › Chapter 3 - Provider Participation › Section XVII-303 - Provider Responsibilities

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Providers may not deliver more than one month's approval of supplies initially
				  and all subsequently approved supplies must be delivered in increments not to
				  exceed one month's rations.
B. The
				  recipient must be Medicaid eligible on the date of service for payment to be
				  made. The date of service is the date of delivery.
C. The date of shipping will be considered
				  the date of service for all items delivered through mail courier
				  service.
D. Providers who make or
				  sell prosthetic or orthotic items must provide a warranty which lasts at least
				  90 days, from the time the item is delivered to the customer. If, during those
				  90 days, the item does not work, the manufacturer or dealer must repair or
				  replace the item.
E. For any
				  appliance which requires skill and knowledge to use, the item provider must
				  provide appropriate training for the recipient and must provide documentation
				  of plans for training upon the request of the prior authorization
				  unit.
AUTHORITY NOTE:
					 Promulgated in accordance with R. S. 36:254 and Title XIX of the Social
					 Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XVII - Prosthetics and Orthotics › Subpart 1 - General Provisions › Chapter 5 - Reimbursement › Section XVII-501 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Effective for dates of service on or after September 6, 2007, the reimbursement
				  for prosthetic and orthotic devices is 90 percent of the 2007 Medicare Fee
				  Schedule amount or billed charges, whichever is the lesser amount, unless
				  otherwise stipulated. If an item is not available at 90 percent of the 2007
				  Medicare fee schedule amount, the flat fee that will be utilized is the lowest
				  cost at which the item has been determined to be widely available by analyzing
				  usual and customary fees charged in the community.
1. This rate does not apply to prosthetics
				  and orthotics that are:
a. already reimbursed
				  at a higher amount than 90 percent of the 2007 Medicare Fee Schedule;
				  or
b. not included on the 2007
				  Medicare Fee Schedule, such as customized items for which there is no
				  established fee. These items must be individually priced.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XVII - Prosthetics and Orthotics › Subpart 1 - General Provisions › Chapter 5 - Reimbursement › Section XVII-503 - Medicare Part B Claims

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Medicare
				  payment to the Medicaid rate on file is compared to the Medicare Part B claims
				  for the prosthetic or orthotic item. If the Medicare payment exceeds the
				  Medicaid rate, the claim is adjudicated as a paid claim with a zero payment. If
				  the Medicaid rate exceeds the Medicare payment, the claim is reimbursed at the
				  lesser of the co-insurance and deductible or up to the Medicaid maximum
				  payment.
B. If the Medicaid payment
				  is reduced or eliminated as a result of the Medicare/Medicaid payment
				  comparison, the amount of the Medicare payment plus the amount of the Medicaid
				  payment (if any) shall be considered to be payment in full for the service. The
				  recipient does not have any legal liability to make payment for the
				  service.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XVII - Prosthetics and Orthotics › Subpart 3 - Prosthetic Devices › Chapter 15 - Artificial Eyes, Scleral Shell, and Related Services › Section XVII-1501 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. Definitions
Artificial Eye or Ocular Prosthesis-
a
					 replacement for a missing or damaged, unsightly eye.
Full Ocular
Prosthesis
-used for individuals who have the globe removed
					 allowing for the fitting of a regular artificial eye.
Related Services
-include polishing or
					 resurfacing of ocular prosthetics, enlargements or reductions of ocular
					 prosthetics, and fabrication or fitting of ocular conformer.
Scleral Shell (or Shield
)-
a. a custom-made, thin ocular prosthesis
				  fitted directly over a blind and shrunken globe. It includes the iris (the
				  colored part of the eye) and the sclera (the white part of the eye);
b. a term utilized to describe different
				  types of hard scleral contact lenses. A shell fits over the entire exposed
				  surface of the eye as opposed to a corneal contact lens which covers only the
				  central nonwhite area encompassing the pupil and iris.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XVII - Prosthetics and Orthotics › Subpart 3 - Prosthetic Devices › Chapter 15 - Artificial Eyes, Scleral Shell, and Related Services › Section XVII-1503 - Medical Necessity

Current through Register Vol. 50, No. 6, June 20, 2024
A. An
				  artificial eye and related services shall be approved if an eyeball is removed
				  and replacement and repair and/or upkeep of an artificial eye are necessary to
				  maintain the contour of the face.
B. A scleral shell may be authorized when the
				  medical criteria as stated in this
				  §1503 are met. A scleral shell may,
				  among other things, obviate the need for surgical enucleation and prosthetic
				  implant and act to support the surrounding orbital tissue of an eye that has
				  been rendered sightless and shrunken by inflammatory disease. In such a case,
				  the device serves essentially as an artificial eye. In this situation,
				  authorization of payment may be made for a scleral shell. Scleral shells are
				  occasionally used in combination with artificial tears in the treatment of "dry
				  eye" of diverse etiology. Tears ordinarily dry at a rapid rate, and are
				  continually replaced by the lacrimal gland. When the lacrimal gland fails, the
				  half-life of artificial tears may be greatly prolonged by the use of the
				  scleral contact lens as a protective barrier against the drying action of the
				  atmosphere. Thus, the difficult and sometimes hazardous process of frequent
				  installation of artificial tears may be avoided. The lens acts in this instance
				  to substitute, in part, for the functioning of the diseased lacrimal gland and
				  may be covered as a prosthetic device in the rare case when it is used in the
				  treatment of "dry eye."
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XVII - Prosthetics and Orthotics › Subpart 5 - Orthotic Devices › Chapter 103 - Orthopedic Shoes and Corrections › Section XVII-10307 - Orthopedic Shoes

Current through Register Vol. 50, No. 6, June 20, 2024
A. Orthopedic shoes
				  and corrections are approved only when the shoes are attached to braces or are
				  needed to protect gains from surgery or casting. Payment will not be made for:
1. metatarsus adductus; or
2. internal tibil torsion.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XVII - Prosthetics and Orthotics › Subpart 5 - Orthotic Devices › Chapter 105 - Osteogenic Bone Growth Stimulators › Section XVII-10501 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Osteogenic bone growth stimulators are used to augment bone repair associated
				  with either a healing fracture or bone fusion.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XVII - Prosthetics and Orthotics › Subpart 5 - Orthotic Devices › Chapter 105 - Osteogenic Bone Growth Stimulators › Section XVII-10503 - Medical Necessity

Current through Register Vol. 50, No. 6, June 20, 2024
A. Spinal
				  noninvasive electrical bone growth stimulators may be considered:
1. when a minimum of nine months has elapsed
				  since the patient has had fusion surgery which has resulted in a failed spinal
				  fusion;
2. when there is a history
				  of a previously failed spinal fusion at the same site following spinal fusion
				  surgery and more than nine months has elapsed since fusion surgery was
				  performed at the same level which is being fused again. As long as nine months
				  has passed since the failed fusion surgery, this repeated fusion attempt
				  requires no minimum passage of time for the application of the device;
				  or
3. following a multi-level
				  spinal fusion (i.e., involving three or more contiguous vertebrae, such as
				  L3-L5 or L4-S1). There is no minimum time for application after this
				  surgery.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XVII - Prosthetics and Orthotics › Subpart 5 - Orthotic Devices › Chapter 105 - Osteogenic Bone Growth Stimulators › Section XVII-10505 - Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. Medicaid
				  coverage shall be limited to reimbursement for noninvasive types of bone growth
				  stimulators only. Medicaid will not provide reimbursement for invasive types of
				  bone growth stimulators.
B.
				  Noninvasive types of bone growth stimulators shall be reimbursed on an
				  item-by-item basis. Reimbursement amounts may be based on:
1. invoiced costs to providers;
2. comparative prices of providers;
3. manufacturer's suggested retail prices;
				  or
4. a flat fee negotiated between
				  the department and the provider.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 39 - General Provisions › Section XIX-3901 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. The Medicaid
				  Program covers medically necessary laboratory and radiology services that are
				  ordered by a physician or other licensed practitioner acting within their scope
				  of practice and:
1. provided by or under the
				  direction of, a physician or other licensed practitioner acting within their
				  scope of practice; or
2. provided
				  by an independent laboratory.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 39 - General Provisions › Section XIX-3903 - Service Limitations

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Providers may only furnish laboratory services for which they are certified
				  under the clinical laboratory improvement amendments.
B. Providers may only receive reimbursements
				  for services that they personally perform or supervise.
C. Effective for dates of service on or after
				  February 20, 2018, the Medicaid Program terminates coverage of proton beam
				  radiation therapy for beneficiaries 21 years of age and older.
1. For beneficiaries under the age of 21,
				  coverage shall be provided when proton beam radiation therapy services are
				  deemed medically necessary.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 41 - Provider Participation › Section XIX-4101 - Physicians and Other Licensed Practitioners Office Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Physicians and
				  other licensed practitioners must comply with all applicable state and federal
				  laws and regulations.
B.
				  Repealed.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 46:153 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 41 - Provider Participation › Section XIX-4103 - Independent Laboratories

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Independent laboratories are freestanding laboratory facilities that are
				  independent of the ordering provider, hospital, or both.
B. Independent laboratories must be licensed
				  in accordance with state laws and regulations.
C. Independent laboratories must comply with
				  all applicable state and federal laws and regulations.
D. Independent laboratories must maintain
				  copies of all laboratory orders and laboratory results for a period of at least
				  five years. Records shall be retained in the laboratory in such a manner that
				  permits ready identification and accessibility.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 46:153 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter A - Billing › Section XIX-4301 - Laboratory Services Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. Providers shall be reimbursed according to
					 the established fee schedule or billed charges, whichever is the
					 lesser.
B. Reimbursement for
					 laboratory services shall not exceed 100 percent of the current years Medicare
					 fee.
C. For newly added laboratory
					 services, the Medicaid fee shall be set at 75 percent of the current year-us
					 Medicare allowable fee.
1. In the absence of a
					 Medicare fee, the fee shall be set at the Medicaid fee for a similar service or
					 the Medicaid fee for other states. In the absence of a similar service or a
					 Medicaid fee for other states, the fee shall be set at the cost of performing
					 the service.
2. Laboratory services
					 related to a declared public health emergency may be reimbursed at up to 100
					 percent of the Medicare allowable fee if deemed necessary by the Medicaid
					 Program to ensure access.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter A - Billing › Section XIX-4303 - Provider Claim Requirements (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						46:153 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter A - Billing › Section XIX-4305 - Automated, Multichannel Test and Panel Billing (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						46:153,
						R.S.
						49:1008(A), and Title XIX of
						the Social Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter A - Billing › Section XIX-4307 - Hepatic Function Panel and General Health Panel (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						46:153,
						R.S.
						49:1008(A), and Title XIX of
						the Social Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter A - Billing › Section XIX-4309 - Hematology (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						46:153,
						R.S.
						49:1008(A), and Title XIX of
						the Social Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter A - Billing › Section XIX-4311 - Panel Codes (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						46:153,
						R.S.
						49:1008(A), and Title XIX of
						the Social Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter A - Billing › Section XIX-4313 - Prenatal Lab Panel Services (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						46:153,
						R.S.
						49:1008(A), and Title XIX of
						the Social Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter A - Billing › Section XIX-4315 - Urinalysis (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						46:153,
						R.S.
						49:1008(A), and Title XIX of
						the Social Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter A - Billing › Section XIX-4317 - Panels and Component Codes within Panels (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254,
						R.S.
						49:1008(A), and Title XIX of
						the Social Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter A - Billing › Section XIX-4319 - X-Ray Equipment Portage Billing (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254, and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter B - Reimbursement › Section XIX-4329 - Laboratory Services (Physicians and Independent Laboratories) (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						46:153,
						R.S.
						49:1008(A), P.L. 98-369, and
						Title XIX of the Social Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter B - Reimbursement › Section XIX-4331 - Medicare Part B (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						46:153,
						R.S.
						49:1008(A), P.L. 98-369, and
						Title XIX of the Social Security Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter B - Reimbursement › Section XIX-4333 - Outpatient Hospital Laboratory Services Reimbursement (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						46:153 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter B - Reimbursement › Section XIX-4334 - Radiology Services Reimbursement Methodology

Current through Register Vol. 50, No. 6, June 20, 2024
A. This reimbursement methodology applies to
					 radiology services including portable x-ray and radiation therapy center
					 services.
B. Providers shall be
					 reimbursed according to the established fee schedule or billed charges,
					 whichever is the lesser amount.
C.
					 For newly added radiology services, the Medicaid fee shall be set at 75 percent
					 of the current year-us Louisiana Region 99 Medicare allowable fee.
1. In the absence of a Medicare fee, the fee
					 shall be set at the Medicaid fee for a similar service or the Medicaid fee for
					 other states. In the absence of a similar service or a Medicaid fee for other
					 states, the fee shall be set at the cost of performing the service.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter B - Reimbursement › Section XIX-4335 - Portable Radiology Services (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 43 - Reimbursement › Subchapter B - Reimbursement › Section XIX-4337 - Radiation Therapy Centers (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
						Promulgated in accordance with
						R.S.
						36:254 and Title XIX of the Social Security
						Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XIX - Other Healthcare Services › Subpart 3 - Laboratory and Radiology Services › Chapter 45 - Radiology Utilization Management (Repealed) › Section XIX-4501 - General Provisions (Repealed)

Current through Register Vol. 50, No. 6, June 20, 2024
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXI - Home and Community-Based Services Waivers › Subpart 1 - General Provisions › Chapter 1 - Freedom of Choice › Section XXI-101 - General Provisions

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  Department of Health may remove a service provider from the waiver provider
				  freedom of choice list and offer freedom of choice to waiver participants when:
1. one or more of the following departmental
				  proceedings are pending against a waiver participant's service provider:
a. revocation of the provider's home and
				  community-based services license;
b. exclusion from the Medicaid
				  Program;
c. termination from the
				  Medicaid Program; or
d. withholding
				  of Medicaid reimbursement as authorized by the department's surveillance and
				  utilization review (SURS) Rule (LAC 50:I.Chapter 41);
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXI - Home and Community-Based Services Waivers › Subpart 1 - General Provisions › Chapter 3 - Eligibility › Section XXI-301 - Termination of Coverage for Displaced Recipients

Current through Register Vol. 50, No. 6, June 20, 2024
A. When a declared disaster occurs and
				  recipients relocate out of state due to the declared disaster, Medicaid
				  coverage of the services they are receiving in home and community-based
				  waivers, shall be terminated under either of the following circumstances:
1. the participant fails to return to
				  Louisiana within 90 days following the initial identified date of the declared
				  disaster; or
EXCEPTION: The department may extend this timeframe due to
					 extenuating circumstances.
2. the participant relocates with no
				  intention of returning to Louisiana.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXI - Home and Community-Based Services Waivers › Subpart 1 - General Provisions › Chapter 3 - Eligibility › Section XXI-303 - Active Duty Military Families

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Any active duty member of the armed forces who has been temporarily assigned to
				  work outside of Louisiana, and any member of his/her immediate family who has
				  qualified for and received home and community-based waiver services provided
				  under the Medicaid Program for persons with developmental disabilities, shall
				  be eligible to receive the next available opportunity for waiver services upon
				  the member's resumed residence in Louisiana.
1. For purposes of these provisions,
				  immediate family shall be defined as the spouse, child, or other person for
				  whom the member of the armed services has guardianship.
Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part XXI - Home and Community-Based Services Waivers › Subpart 1 - General Provisions › Chapter 3 - Eligibility › Section XXI-305 - Continued Eligibility

Current through Register Vol. 50, No. 6, June 20, 2024
A. Home and
				  community-based providers shall report to the operating agency when/if it
				  becomes known to the agency that a participants status has changed such that
				  the participant no longer meets programmatic or financial eligibility
				  requirements.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 36:254 and Title XIX of the Social Security
					 Act.