Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.57 - Child Care Medical Services

Current through Register Vol. 47, No. 3, July 24, 2024
Payments will be made to licensed child care centers that
				  provide medical services in addition to child care. Medically necessary
				  services are provided under a plan of care that is developed by licensed
				  professionals within their scope of practice and authorized by the member's
				  physician. The services include and implement a comprehensive protocol of care
				  that is developed in conjunction with the parent or guardian and specifies the
				  medical, nursing, personal care, psychosocial and developmental therapies
				  required by the medically dependent or technologically dependent child
				  served.
(1) Nursing services are
				services which are provided by a registered nurse or a licensed practical nurse
				under the direction of the member's physician to a member in a licensed child
				care center. Nursing services shall be provided according to a written plan of
				care authorized by a physician. Payment for nursing services may be approved if
				the services are determined to be medically necessary as defined in subrule
				78.57(5). Nursing services include activities that require the expertise of a
				nurse, such as physical assessment, tracheostomy care, medication
				administration, and tube feedings.
(2) Personal care services are those services
				which are provided by an aide but are delegated and supervised by a registered
				nurse under the direction of the member's physician. Payment for personal care
				services may be approved if the services are determined to be medically
				necessary as defined in subrule 78.57(5). Personal care services shall be in
				accordance with the member's plan of care and authorized by a physician.
				Personal care services include the activities of daily living, oral hygiene,
				grooming, toileting, feeding, range of motion and positioning, and training the
				member in necessary self-help skills, including teaching prosocial skills and
				reinforcing positive interactions.
(3) Psychosocial services are those services
				that focus at decreasing or eliminating maladaptive behaviors. Payment for
				psychosocial services may be approved if the services are determined to be
				medically necessary as defined in subrule 78.57(5). Psychosocial services shall
				be in accordance with the member's plan of care and authorized by a physician.
				Psychosocial services include implementing a plan using clinically accepted
				techniques for decreasing or eliminating maladaptive behaviors. Psychosocial
				intervention plans must be developed and reviewed by licensed mental health
				providers.
(4) Developmental
				therapies are those services which are provided by an aide but are delegated
				and supervised by a licensed therapist under the direction of the member's
				physician. Payment for developmental therapies may be approved if the services
				are determined to be medically necessary as defined in subrule 78.57(5).
				Developmental therapies shall be in accordance with the member's plan of care
				and authorized by a physician. Developmental therapies include activities based
				on the individual's needs such as fine motor, gross motor, and receptive
				expressive language.
(5) "Medically
				necessary" means the service is reasonably calculated to prevent, diagnose,
				correct, cure, alleviate or prevent the worsening of conditions that endanger
				life, cause pain, result in illness or infirmity, or threaten to cause or
				aggravate a disability or chronic illness and is an effective course of
				treatment for the member requesting a service.
(6) Requirements.
a. Nursing, psychosocial, developmental
				therapies and personal care services shall be ordered in writing.
b. Nursing, psychosocial, developmental
				therapies and personal care services shall be authorized by the department or
				the department's designated review agent prior to payment.
c. Prior authorization shall be requested at
				the time of initial submission of the plan of care or at any time the plan of
				care is substantially amended and shall be renewed with the department or the
				department's designated review agent. Initial request for and request for
				renewal of prior authorization shall be submitted to the department's
				designated review agent. The provider of the service is responsible for
				requesting prior authorization and for obtaining renewal of prior
				authorization. The request for prior authorization shall include a nursing
				assessment, the plan of care, and supporting documentation. A treatment plan
				shall be completed prior to the start of care and at a minimum reviewed every
				180 days thereafter. The plan of care shall support the medical necessity and
				intensity of services to be provided by reflecting the following information:
(1) Place of service.
(2) Type of service to be rendered and the
				treatment modalities being used.
(3) Frequency of the services.
(4) Assistance devices to be used.
(5) Date on which services were
				initiated.
(6) Progress of member
				in response to treatment.
(7)
				Medical supplies to be furnished.
(8) Member's medical condition as reflected
				by the following information, if applicable:
1. Dates of prior hospitalization.
2. Dates of prior surgery.
3. Date last seen by a primary care
				provider.
4. Diagnoses and dates of
				onset of diagnoses for which treatment is being rendered.
5. Prognosis.
6. Functional limitations.
7. Vital signs reading.
8. Date of last episode of acute recurrence
				of illness or symptoms.
9.
				Medications.
(9)
				Discipline of the person providing the service.
(10) Certification period.
(11) Physician's signature and date. The
				treatment plan must be signed and dated by the physician before the claim for
				service is submitted for reimbursement.
(12) Form 470-5686 is utilized during the
				prior authorization review.