reglab/statecodes huggingface dataset:
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 18 - PHYSICIANS' SERVICES › Section 471-18-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
COMPREHENSIVE
  INTERDISCIPLINARY TREATMENT.
The collaboration of medicine,
  psychology, nutrition science, speech therapy, occupational therapy, social
  work, and other appropriate medical and behavioral disciplines in an integrated
  program.
002.02
CONSULTING PHYSICIAN.
A physician whose services
  include history taking, examination of the individual, and, in each case,
  furnishing to the attending physician an opinion regarding diagnosis or
  treatment. A physician providing clinical laboratory services for individuals
  of other physicians is not considered a consulting physician.
002.03
EMERGENCY MEDICAL
  CONDITION.
A medical behavior or condition, the onset of which is
  sudden, manifesting itself by symptoms of sufficient severity such that the
  absence of immediate medical attention could result in:
(A) Placing the health of the individual or
  with respect to a pregnant woman, the health of the woman or her unborn child,
  in serious jeopardy;
(B) Serious
  impairment to such person's bodily functions; or
(C) Serious dysfunction of any bodily organ
  or part.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 18 - PHYSICIANS' SERVICES › Section 471-18-003 - PROVIDER REQUIREMENTS

Current through June 17, 2024
003.01
GENERAL PROVIDER REQUIREMENTS.
To participate in
  Nebraska Medicaid, providers of physician services must comply with all
  applicable provider participation requirements codified in 471 Nebraska
  Administrative Code (NAC) 2 and 3. In the event provider participation
  requirements in 471 NAC 2 or 3 conflict with requirements outlined in this 471
  NAC 18, the individual provider participation requirements in 471 NAC 18 will
  govern.
003.02
SPECIFIC
  PROVIDER REQUIREMENTS.
003.02(A)
INDEPENDENT CLINICAL LABORATORIES.
An independent
  clinical laboratory must have a separate provider agreement with the
  Department. In addition to the provider agreement, independent clinical
  laboratories must meet the following requirements:
(i) When state or applicable local law
  requires licensing of independent clinical laboratories, the laboratory must be
  licensed under the law; and
(ii)
  The laboratory must meet the health or safety requirements of the United States
  Secretary of Health and Human Services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 18 - PHYSICIANS' SERVICES › Section 471-18-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
MEDICAL NECESSITY.
The definition of medical necessity
  from 471 NAC 1 is incorporated as if fully rewritten herein. Services and
  supplies which do not meet the 471 NAC 1 definition of medical necessity are
  not covered. Physicians' services may be provided at the physician's office,
  the individual's home, a hospital, a long term care facility, or elsewhere.
  Additionally, Nebraska Medicaid covers medically necessary physicians' services
  within program guidelines which are provided:
(A) Within the scope of the practice of
  medicine or osteopathy as defined by Nebraska state law; and
(B) By, or under the personal supervision of,
  an individual licensed under Nebraska state law to practice medicine or
  osteopathy.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 18 - PHYSICIANS' SERVICES › Section 471-18-005 - COVERED SERVICES

Current through June 17, 2024
005.01
FACILITY-BASED PHYSICIAN CLINICS.
Physician clinic
  services provided in a hospital location or a facility under the hospital's
  licensure are considered to be a physician service, not an outpatient hospital
  service.
(A) The Department does not recognize
  facility or hospital-based non-emergency physician clinics for billing,
  reimbursement, or cost reporting purposes except for itinerant physicians as
  defined in 471 NAC 18.
(B) Services
  and supplies incident to a physician's professional service provided during a
  specific encounter are covered and reimbursed as physician clinic services if
  the service or supply is:
(i) Of the type
  commonly furnished in a physician's office;
(ii) Furnished as an incidental, although
  integral, part of the physician professional service; and
(iii) Furnished under the direct personal
  supervision of the physician.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 18 - PHYSICIANS' SERVICES › Section 471-18-008 - PAYMENT

Current through June 17, 2024
008.01
GENERAL PAYMENT
  REQUIREMENTS.
Nebraska Medicaid will reimburse the Provider for
  services rendered in accordance with the applicable payment regulations
  codified in 471 NAC 3. In the event individual payment regulations in 471 NAC 3
  conflict with payment regulations outlined in this chapter, the individual
  payment regulations in this chapter will govern
008.02
SPECIFIC PAYMENT
  REQUIREMENTS.
008.02(A)
REIMBURSEMENT.
Nebraska Medicaid pays for covered
  physician services, except clinical laboratory services, at the lower of the
  provider's submitted charge or the allowable amount for the procedure code in
  the Nebraska Medicaid Practitioner Fee Schedule in effect for the date of
  service.
008.02(A)(i)
EXCEPTION.
The Department may enter into an agreement
  with an out-of-state provider for a rate which exceeds the rate according to
  the Nebraska Medicaid Practitioner Fee Schedule only when the Department has
  determined the individual requires specialized services which are not available
  in Nebraska and no other source of the specialized service can be
  found.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 18 - PHYSICIANS' SERVICES › Section 471-18-009 - PRESCRIPTION DRUG MONITORING PROGRAM

Current through June 17, 2024
009.01
GENERAL REQUIREMENT.
Each provider prescribing a
  controlled substance in Nebraska to a Medicaid client must check the
  prescription drug monitoring program established under Neb. Rev. Stat. §
									71-2454
  before prescribing a schedule II medication and at dosage adjustment. Provider
  may delegate checking of the prescription drug monitoring program to a delegate
  as defined in Neb. Rev. Stat. §
									71-2454(14)(c).
009.02
EXCEPTION.
Good faith exceptions must be documented in the client's medical record and
  provided upon request to the Department. These requirements do not include a
  prescription to a client as set forth under
  42
  U.S.C. Sec. 1396w-3a and to a resident of a
  facility where schedule II medications are dispensed to a client through a
  single pharmacy.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 19 - PODIATRY SERVICES › Section 471-19-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
The regulations govern the services provided under Nebraska's Medicaid
	 program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§
									68-901
	 et seq.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 19 - PODIATRY SERVICES › Section 471-19-003 - PROVIDER REQUIREMENTS

Current through June 17, 2024
003.01
GENERAL PROVIDER REQUIREMENTS.
To participate in Nebraska
  Medicaid, providers of podiatry services must comply with all applicable
  participation requirements codified in 471 Nebraska Administrative Code (NAC)
  1, 2 and 3. In the event that provider participation requirements in 471 NAC
  1,2 or 3 conflict with requirements outlined in 471 NAC 19, the individual
  provider participation requirements in 471 NAC 19 will govern.
003.02
SERVICE SPECIFIC PROVIDER
  REQUIREMENTS.
Podiatrists must be licensed by the Nebraska
  Department of Health and Human Services, Division of Public Health. If podiatry
  services are provided outside Nebraska, the podiatrist must be licensed in that
  state. I
003.03(A)
PROVIDER
  AGREEMENT.
The podiatrist will complete and sign a Medical
  Assistance Provider Agreement, and submit the completed form to the Department
  for approval to participate in Nebraska Medicaid.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 19 - PODIATRY SERVICES › Section 471-19-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
GENERAL REQUIREMENTS.
004.01(A)
MEDICAL NECESSITY.
Nebraska Medicaid incorporates the
  definition of medical necessity from 471 NAC 1. Services and supplies that do
  not meet the 471 NAC) 1 definition of medical necessity are not
  covered.
004.01(B)
SERVICES PROVIDED FOR RECIPIENTS ENROLLED IN THE NEBRASKA I
  MEDICAID MANAGED CARE PROGRAM. See 471 NAC 1.
004.01(C)
EARLY AND PERIODIC,
  SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) SERVICES. See 471 NAC
  33.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 19 - PODIATRY SERVICES › Section 471-19-005 - BILLING AND PAYMENT FOR SERVICES

Current through June 17, 2024
005.01
BILLING.
005.01(A)
GENERAL BILLING REQUIREMENTS.
Providers must comply
  with all applicable billing requirements codified in 471 NAC 3. In the event
  that billing requirements in 471 NAC 3 conflict with billing requirements
  outlined in 471 NAC 19, the billing requirements in 471 NAC 19 will
  govern.
005.01(B)
SPECIFIC BILLING REQUIREMENTS.
005.01(B)(i)
BILLING
  INSTRUCTIONS.
Providers must bill Nebraska Medicaid using the
  appropriate claim form or electronic format.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 20 - PSYCHIATRIC SERVICES FOR INDIVIDUALS AGE 21 AND OLDER › Section 471-20-002 - Outpatient Psychiatric Services

Current through June 17, 2024
Note: All requirements in 471 NAC
	 20-001 apply to outpatient
	 psychiatric services.
002.01
Covered Outpatient Psychiatric Therapeutic Services
Nebraska Medical Assistance Program covers the following outpatient
	 psychiatric therapeutic services for clients age 21 and older as defined in 471
	 NAC 20-001.12:
1. Psychiatric
  evaluation;
2. Psychological
  evaluation;
3. Psychological
  testing;
4. Individual
  Psychotherapy;
5. Group
  Psychotherapy (a group overview must be approved by Medicaid prior to billing
  for this service);
6. Family
  Psychotherapy Services;
7. Family
  Assessment;
8. Medication checks by
  a physician or a physician extender;
9. Electroconvulsive Therapy.
Treatment for chemical dependency is not covered for clients age 21 and
	 older.
Skilled nursing services for the monitoring of medications is available
	 through Home Health Agencies (see 471 NAC 9-000).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 20 - PSYCHIATRIC SERVICES FOR INDIVIDUALS AGE 21 AND OLDER › Section 471-20-003 - Adult Day Treatment Psychiatric Services

Current through June 17, 2024
Psychiatric day treatment is a service in a continuum of care designed
	 to prevent hospitalization or to facilitate the movement of the acute
	 psychiatric client to a status in which the client is capable of functioning
	 within the community with less frequent contact with the psychiatric health
	 care provider.
Day treatment services must meet all requirements in 471 NAC
	 20-001.
003.01
Covered Day Treatment
  Services
Psychiatric day treatment programs shall provide the following
	 mandatory services and at least two of the following optional services. Payment
	 for both mandatory services and optional services is included in the rate for
	 day treatment. Providers shall not make any additional charges to the
	 Department or to the client.
20-003.01A
Mandatory
  Services
: The following services must be included in a program for
  psychiatric day treatment to be approved for participation in the Nebraska
  Medical Assistance Program. See 471 NAC
  20-001 for definitions.
1.
Medically Necessary
  Psychotherapy Services
: These services must demonstrate active
  treatment of a patient with a psychiatric condition. These services are subject
  to program limitations and must be provided by professionals operating within
  the appropriate scope of practice.
a.
  Individual Psychotherapy;
b. Group
  Psychotherapy;
c. Family
  Psychotherapy;
d. Family Assessment
  if appropriate;
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 20 - PSYCHIATRIC SERVICES FOR INDIVIDUALS AGE 21 AND OLDER › Section 471-20-006 - Adult Subacute Inpatient Hospital Psychiatric Services

Current through June 17, 2024
Subacute inpatient hospital psychiatric services for clients 21 and
	 over are medically necessary short-term psychiatric services provided to a
	 client. The care and treatment of a subacute inpatient with a primary
	 psychiatric diagnosis must be under the direction of a Nebraska licensed
	 psychiatrist who meets the state's licensing criteria and is enrolled as a
	 Medicaid provider with the Department. Subacute inpatient hospital psychiatric
	 services must be prior-authorized by the Department-contracted peer review
	 organization or management designee. In addition, out-of-state subacute
	 hospitalizations must be approved by the Department.
006.01
Provider
  Agreement
A hospital that provides subacute inpatient psychiatric services must
	 complete Form MC-20, "Medical Assistance Hospital Provider Agreement," (see
	 471-000-91) and submit the completed form to the Department for approval and
	 enrollment as a Medicaid provider of subacute inpatient hospital psychiatric
	 services. The hospital must submit with the provider agreement:
1. A complete description of the psychiatric
  program and the elements of the program (i.e., policies and procedures,
  staffing, services, etc.);
2. A
  statement of the total number of licensed inpatient psychiatric beds,
  designated as subacute psychiatric beds that are approved by the Nebraska
  Department of Health and Human Services, Division of Public Health or agency in
  the state in which the facility is located; a listing of the bed numbers for
  those licensed psychiatric beds; and the size of the proposed subacute
  inpatient psychiatric unit;
3.
  Documentation that the subacute inpatient program meets the family-centered,
  community-based requirements in 471 NAC
  20-001;
4. A description of how individual, group,
  and family psychotherapy services as well as other psycho-educational and
  rehabilitation services will be provided;
5. A description of how the subacute
  inpatient hospital psychiatric services will interface with community services
  for discharge planning and service provision after discharge;
6. A copy of the most recent Joint Commission
  Accreditation of Healthcare Organizations (JCAHO) or the American Osteopathic
  Association (AOA) accreditation survey; and
7. Any other information requested.
Any facility requesting a provider agreement must make the facility
	 available for an on-site review before issuance of a provider
	 agreement.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 20 - PSYCHIATRIC SERVICES FOR INDIVIDUALS AGE 21 AND OLDER › Section 471-20-007 - Adult Inpatient Hospital Psychiatric Services

Current through June 17, 2024
Inpatient hospital psychiatric services for clients 21 and over are
	 medically necessary psychiatric services provided to an inpatient as defined in
	 471 NAC 10-000. The care and treatment of an inpatient with a primary
	 psychiatric diagnosis must be under the direction of a psychiatrist or
	 physician who meets the state's licensing criteria and is enrolled as a
	 provider with the Department with a primary specialty of psychiatry. Inpatient
	 hospital psychiatric services must be prior-authorized by the
	 Department-contracted peer review organization or management designee. In
	 addition, out-of-state hospitalizations must be approved by the
	 Department.
007.01
Provider Agreement
A hospital which provides inpatient psychiatric services shall
	 complete Form MC-20, "Medical Assistance Hospital Provider Agreement," (see
	 471-000-91) and submit the completed form to the Department for approval and
	 enrollment as a provider. The hospital shall submit with the provider agreement
	 -
1. A complete description of the
  psychiatric program and the elements of the program (i.e., policies and
  procedures, staffing, services, etc.);
2. A statement of the total number of
  licensed psychiatric beds, as approved by the Nebraska Department of Health and
  Human Services, Division of Public Health or agency in the state in which the
  facility is located; a listing of the bed numbers for those licensed
  psychiatric beds; and the size of the proposed psychiatric unit;
3. Documentation that the inpatient program
  meets the family-centered, community-based requirements in 471 NAC
  20-001;
4. A description of how family psychotherapy
  services will be provided;
5. A
  description of how the hospital services will interface with community services
  for discharge planning and service provision after discharge;
6. A copy of the most recent JCAHO or AOA
  accreditation survey; and
7. Any
  other information requested.
Any facility requesting a provider agreement shall make the facility
	 available for an on-site review before issuance of a provider
	 agreement.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 21 - REHABILITATION CARE IN HOSPITALS › Section 471-21-001 - Definitions

Current through June 17, 2024
Activities of Daily Living:
Activities
	 performed by the client relating to self-care, such as bathing, continence,
	 eating, dressing, grooming, mobility, toileting, and transferring.
Distinct Part Unit:
A Medicare-certified
	 hospital-based substance abuse, psychiatric, or physical rehabilitation unit
	 that is certified as a distinct part unit for Medicare.
Initial Evaluation:
See 471 NAC
	 21-003.02A
Rehabilitation Hospitals and Distinct Part Units in Acute
	 Care Hospitals:
Hospitals that are licensed as rehabilitation
	 hospitals by the licensing agency of the state in which they are located, and
	 distinct parts as defined in these regulations.
Rehabilitation Services:
Any medical or
	 remedial services recommended by and within the scope of practice under state
	 law of a physicianw, for maximum reduction of physical or mental disability and
	 restoration of a client to the client's best possible functional level.
Rehabilitation Team:
A multidisciplinary
	 coordinated team, comprised of individuals described in 471 NAC
	 21-003.02(i)-(vii),
	 which is responsible for performing the initial evaluation, determining the
	 extent to which rehabilitation is possible, identifying rehabilitation goals,
	 and developing the rehabilitation program.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 21 - REHABILITATION CARE IN HOSPITALS › Section 471-21-003 - Service Requirements

Current through June 17, 2024
21-003.01
General
  Requirements
21.003.01A
Medical Necessity
: Rehabilitation services must be
  provided in accordance with the medical necessity guidelines outlined in 471
  NAC
  1-002.02A.
21.003.01B
Prior Authorization of
  Medical Rehabilitation Care
: Medicaid requires prior authorization
  of all medical inpatient rehabilitation services to determine the medical
  necessity, appropriateness of setting, and length of stay. Prior authorization
  functions, admission reviews, concurrent reviews, and retrospective prepayment
  reviews are conducted by the peer review organization (PRO), an entity
  contracted with Medicaid to perform these services. The PRO also performs
  reconsideration reviews of inpatient hospital denials when requested by the
  provider.
21.003.01C
Services Provided for Clients Enrolled in the Nebraska Medicaid
  Managed Care Program
: See 471 NAC 1-002.01.
21.003.01C1
Delayed
  Enrollment
: When a client is in an acute care medical or
  rehabilitation facility prior to the client's enrollment in Managed Care, the
  effective date of enrollment is delayed until the client is discharged from the
  facility or transferred to a lower level of care. See 482 NAC
  2-002.05D.
21.003.01D
HEALTH CHECK (EPSDT)
  Treatment Services
: See 471 NAC Chapter 33
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 21 - REHABILITATION CARE IN HOSPITALS › Section 471-21-004 - Billing and Payment for Chiropractic Services

Current through June 17, 2024
21-004.01
Billing
21-004.01A
General Billing
  Requirements
: Providers shall comply with all applicable billing
  requirements codified in 471 NAC Chapter 3. In the event that billing
  requirements in 471 NAC Chapter 3 conflict with billing requirements outlined
  in this 471 NAC Chapter 21, the billing requirements in 471 NAC Chapter 21
  shall govern.
21-004.01B
Specific Billing Requirements
21-004.01B1
Billing
  Instructions
: The provider shall bill Medicaid in accordance with
  the billing instructions included in this Chapter
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 21 - REHABILITATION CARE IN HOSPITALS › Section 471-21-005 - Evaluation Report and Plan of Care

Current through June 17, 2024
The hospital shall submit an evaluation report to the Medical Director
	 of the Division of Medicaid and Long-Term Care, or the Medicaid designated
	 contractor, by the end of the second week following admission. The evaluation
	 report must outline a detailed plan of care, and identify time frames
	 applicable to each goal included in the rehabilitation program. The plan of
	 care must contain a detailed staff report describing the client's:
1. Progress;
2. Problems; and
3. Discharge planning, involving possible
  relocation of the client to the most appropriate setting.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 22 - RESPIRATORY THERAPY SERVICES › Section 471-22-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
The regulations govern the services provided under Nebraska's Medicaid
	 program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§
									68-901
	 et seq.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 22 - RESPIRATORY THERAPY SERVICES › Section 471-22-002 - DEFINITIONS

Current through June 17, 2024
002.01
RESPIRATORY
  THERAPY.
Services that are prescribed by a physician for the
  assessment, diagnostic evaluation, treatment, management, and monitoring of
  patients with deficiencies and abnormalities of cardiopulmonary function.
  Performed by respiratory therapists or technicians, physical therapists, nurses
  and other qualified personnel.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 22 - RESPIRATORY THERAPY SERVICES › Section 471-22-003 - PROVIDER REQUIREMENTS

Current through June 17, 2024
003.01
GENERAL PROVIDER REQUIREMENTS.
To participate in
  Nebraska Medicaid, providers of respiratory therapy services must comply with
  ail applicable participation requirements codified in 471 Nebraska
  Administrative Code (NAC) 1, 2 and 3. In the event that provider participation
  requirements in 471 NAC 1, 2 or 3 conflict with requirements outlined in 471
  NAC 23, the individual provider participation requirements in 471 NAC 22 will
  govern.
003.02
SERVICE
  SPECIFIC PROVIDER REQUIREMENTS.
Respiratory therapy services must
  be provided by or under the direct supervision of a respiratory therapist
  licensed by the Nebraska Department of Health and Human Services, Division of
  Public Health, or, if provided out of state, similarly recognized by the
  respiratory therapy association or licensing entity of that state.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 22 - RESPIRATORY THERAPY SERVICES › Section 471-22-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
GENERAL SERVICE REQUIREMENTS.
004.01(A)
MEDICAL
  NECESSITY.
Nebraska Medicaid incorporates the definition of
  medical necessity from 471 NAC 1. Services and supplies that do not meet the
  471 NAC 1 definition of medical necessity are not covered. In addition to
  meeting these requirements, respiratory therapy services are considered to be
  reasonable and necessary for the diagnosis or treatment of an individual's
  illness or injury only if they also satisfy additional conditions.
004.01(B)
CONDITIONS IN ADDITION
  TO MEDICAL NECESSITY.
004.01(B)(i)
CONSISTENT WITH THE
  NATURE AND SEVERITY OF THE INDIVIDUAL'S COMPLAINTS AND DIAGNOSIS.
A patient's primary diagnosis alone must justify the need for respiratory
  therapy, if the primary diagnosis alone is insufficient, the need for
  respiratory therapy must be justified by medical evidence documenting the need
  based on:
(1) The combination of secondary and
  primary diagnoses: or
(2) The
  severity of the secondary diagnosis alone.
004.01(B)(ii)
REASONABLE IN TERMS
  OF MODALITY AMOUNT FREQUENCY AND DURATION OF THE TREATMENTS.
In
  addition to being considered reasonable and necessary based on the nature and
  severity of the patient's condition, respiratory therapy must also be
  reasonable and necessary with respect to modality, amount, frequency, and
  duration of treatments.
004.01(B)(ii)(1)
DISCHARGE.
It is expected that the level and intensity
  of the care is modified as discharge nears, if the amount and frequency of
  respiratory therapy provided throughout the hospital stay remains constant and
  the primary or secondary diagnosis indicates that under normal circumstances, a
  decline in amount and frequency could be anticipated, the provider must submit
  an explanation to Nebraska Medicaid.
004.01(B)(iii)
GENERALLY ACCEPTED
  BY THE PROFESSIONAL COMMUNITY AS BEING SAFE AND EFFECTIVE TREATMENT FOR THE
  PURPOSE USED.
In the absence of evidence to the contrary, it may
  be presumed that respiratory therapy is an accepted treatment and may be
  covered.
004.01(C)
PHYSICIAN CERTIFICATION.
Respiratory therapy services
  must be provided only on written orders by a licensed Nebraska physician, or,
  if provided out of state, a licensed physician of that state. Services must be
  recertified by a physician every 30 days, or more frequently if the patient's
  condition necessitates.
004.01(D)
ADDITIONAL GUIDELINES FOR COVERAGE CRITERIA. Medicaid covers
respiratory therapy services only when there is a distinction, or
  decision, made with respect to the individual patient's condition and the need
  for the services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 22 - RESPIRATORY THERAPY SERVICES › Section 471-22-005 - BILLING AND PAYMENT FOR RESPIRATORY THERAPY SERVICES

Current through June 17, 2024
005.01
BILLING.
005.01(A)
GENERAL BILLING
  REQUIREMENTS.
Providers must comply with ail applicable billing
  requirements codified in 471 NAC 3. In the event that individual billing
  requirements in 471 NAC 3 conflict with billing requirements outlined in this
  471 NAC 22, the individual billing requirements in 471 NAC 22 will
  govern.
005.01(B)
SPECIFIC BILLING REQUIREMENTS.
005.01(B)(i)
PROCEDURE
  CODES.
The provider must use the appropriate American Medical
  Association's Current Procedural Terminology (CPT) or Healthcare Common
  Procedure Coding System (HCPCS) procedure codes when billing Nebraska
  Medicaid.
005.01(B)(ii)
REQUIRED CLAIMS.
Depending on the place of service,
  the provider must bill as follows:
(1) If the
  service is provided in a hospital, the hospital makes payment to the
  respiratory therapist. The hospital submits claims to Nebraska Medicaid for
  respiratory therapy services provided in the hospital to inpatients and
  outpatients using the appropriate claim form or electronic format; or
(2) If the service is provided in a long term
  care facility, the facility must contract for services not readily available in
  the facility. Depending on the type of provider, reimbursement is claimed as
  follows:
(a) If services are provided by
  another licensed hospital or rehabilitation agency, the long term care facility
  makes payment to the provider. The long term care facility is reimbursed for
  the payment as an allowable cost under the long term care reimbursement plan;
  or
(b) If services are provided by
  a facility staff member or by an individual under contract to the facility, the
  long term care facility makes payment to the individual. The facility is
  reimbursed under the long term care reimbursement plan.
005.01(B)(iii)
DOCUMENTATION.
Respiratory therapy services are
  subject to pre-or post payment utilization reviews. To help determine medical
  necessity for the treatments provided fay the therapist, the following
  documentation must accompany each outpatient hospital claim:
(1) A copy of the respiratory therapist's
  progress notes and anticipated goals; and
(2) Information on the claim or as an
  attachment that includes:
(a) The location
  where the services were provided:
(b) The date of onset of the patient's
  condition: and
(c) The patient's
  diagnosis.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 23 - SPEECH PATHOLOGY AND AUDIOLOGY SERVICES › Section 471-23-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
The regulations govern the services provided under Nebraska's Medicaid
	 program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§
									68-901
	 et seq.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 23 - SPEECH PATHOLOGY AND AUDIOLOGY SERVICES › Section 471-23-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
AUDIOLOGIST.
An individual who practices audiology and who presents their self to the public
  by any title or description of services incorporating the words audiologist
  hearing clinician, or hearing therapist or any similar title or description of
  services.
002.02
PRACTICE OF AUDIOLOGY.
The application of
  evidence-based practice in clinical decision making for the prevention,
  assessment habilitation, rehabilitation, and maintenance of persons with
  hearing, auditory function, and vestibular function impairments and related
  impairments. Practice of audiology does not include the practice of medical
  diagnosis, medical treatment, or surgery. Practices do include:
(A) Cerumen removal from the cartilaginous
  outer one-third portion of the external auditory canal when the presence of
  cerumen may affect the accuracy of hearing evaluations or impressions of the
  ear canal for amplification devices; and
(B) Evaluation, selection, fitting, and
  dispensing of hearing instruments, external processors of implantable hearing
  instruments, and assistive technology devices as part of a comprehensive
  audiological rehabilitation program.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 23 - SPEECH PATHOLOGY AND AUDIOLOGY SERVICES › Section 471-23-003 - PROVIDER REQUIREMENTS

Current through June 17, 2024
003.01
GENERAL PROVIDER REQUIREMENTS.
To participate in
  Medicaid, providers of speech pathology and audiology services must comply will
  all applicable provider participation requirements codified in 471 Nebraska
  Administrative Code (NAO 1, 2, and 3. in the event that provider participation
  requirements in 471 NAC 1, 2, or 3 conflict with requirements outlined in this
  471 NAC 23, the individual provider participation requirements in 471 NAC 23
  will govern.
003.02
SPECIFIC PROVIDER REQUIREMENTS.
If speech pathology or
  audiology services are provided outside Nebraska, the speech pathologist or
  audiologist must be licensed by the state in which the services are provided.
  If the applicable state does not provide licensure for speech pathologists or
  audiologists, the provider must:
(A) Have
  been granted a certificate of competency by the American Speech. Language, and
  Hearing Association. A photocopy of the certificate of competency must be
  submitted to the Department with a signed and completed Medical Assistance
  Provider Agreement:
(B) Meet the
  equivalent educational and work experience requirements needed for a
  certificate of competency; or
(C)
  Have completed the academic program requirements and be acquiring the
  supervised work experience needed for the certificate of competency.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 23 - SPEECH PATHOLOGY AND AUDIOLOGY SERVICES › Section 471-23-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
GENERAL SERVICE REQUIREMENTS.
004.01(A)
MEDICAL
  NECESSITY.
Medicaid incorporates the definition of medical
  necessity inform 471 NAC 1 as if fully rewritten herein. Services and supplies
  that do not meet the 471 NAC 1 definition of medical necessity are not
  covered.
004.01(B)
SERVICE CRITERIA.
Medicaid covers speech pathology and
  audiology services when the following criteria are met. The service must be:
(i) An evaluation:
(ii) Restorative therapy with a medically
  appropriate expectation that the recipient's condition will improve
  significantly within a reasonable period of time; or
(iii) For physical therapy services only,
  recommended in a Department- approved Individual Program Plan (IPP) and the
  recipient is receiving services through one of the following waiver programs:
(1) Comprehensive Developmental Disabilities
  Services Waiver;
(2) Developmental
  Disabilities Adult Residential Services Waiver;
(3) Adult Comprehensive Waiver; or
(4) Home and Community Based Services Waiver
  for Aged Adults and Children with Disabilities.
004.01(C)
SERVICES PROVIDED FOR
  RECIPIENTS ENROLLED IN THE NEBRASKA MEDICAID MANAGED CARE PROGRAM.
See 471 NAC 1.
004.01(D)
EARLY PERIODIC, DIAGNOSTIC AND TREATMENT TREATMENT (EPSDT)
  SERVICES.
See 471 NAC 33.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 23 - SPEECH PATHOLOGY AND AUDIOLOGY SERVICES › Section 471-23-005 - BILLING AND PAYMENT FOR SPEECH PATHOLOGY AND AUDIOLOGY SERVICES

Current through June 17, 2024
005.01
BILLING.
005.01(A)
GENERAL BILLING
  REQUIREMENTS.
Providers must comply with all applicable billing
  requirements codified in 471 NAC 3. In the event that individual billing
  requirements in 471 NAC 3 conflict with billing requirements outlined in this
  471 NAC 23, the individual billing requirements in 471 NAC 23 will
  govern.
005.01(B)
SPECIFIC BILLING REQUIREMENTS.
005.01(B)(i)
BILLING
  INSTRUCTIONS.
The Provider must bill Nebraska Medicaid, using the
  appropriate claim form or electronic format.
005.01(B)(ii)
USUAL AND CUSTOMARY
  CHARGE.
The provider, or their authorized agent, must submit the
  provider's usual and customary charge for services rendered.
005.01(B)(iii)
MEDICAL NECESSITY
  DOCUMENTATION.
The provider must list the following information
  when submitting a claim for speech pathology or audiology services:
(1) Date of illness or injury
  onset:
(2) Date speech pathology or
  audiology plan established:
(3)
  Date speech pathology or audiology started; and
(4) Number of speech pathology or audiology
  visits from onset.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 24 - VISUAL CARE SERVICES › Section 471-24-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
The regulations govern the services provided under Nebraska's Medicaid
	 program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) 68-901 et
	 seq.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 24 - VISUAL CARE SERVICES › Section 471-24-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
EYEGLASSES.
A
  set of both lenses and a frame, used to correct deficiencies in
  vision.
002.02
SIMPLE
  PHOTOPHOBIA.
A photophobia condition which is not caused by a
  disease or other significant health issue. Also referred to as a
  sensitivity.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 24 - VISUAL CARE SERVICES › Section 471-24-003 - PROVIDER REQUIREMENTS

Current through June 17, 2024
003.01
GENERAL PROVIDER REQUIREMENTS.
To participate in Nebraska
  Medicaid, providers of visual care services must comply with all applicable
  participation requirements codified in 471 Nebraska Administrative Code (NAC)
  1,2 and 3. In the event that participation requirements in 471 NAC 1, 2 or 3
  conflict with requirements outlined in this 471 NAC 24, the participation
  requirements in 471 NAC 24 will govern.
003.02
SERVICE SPECIFIC PROVIDER
  REQUIREMENTS.
To participate in Nebraska Medicaid, providers of
  visual care services must:
(1) Be enrolled in
  Nebraska Medicaid by complying with provider agreement requirements:
(2) Be licensed to practice by the Nebraska
  Department of Health and Human Services, Division of Public Health, or if the
  service is provided in another state, be licensed by the other state;
(3) Practice within their scope of practice
  as defined in Neb. Rev. Stat. 38-2601 to 38-2623, or if the service is provided
  in another state, within the scope of practice as defined by the licensing laws
  of the other state; and
(4) Comply
  with all applicable state and federal laws and regulations governing the
  provision of their services.
003.02(A)
PROVIDER AGREEMENT.
Providers of visual care services
  must complete and sign Form MC-19, Service Provider Agreement, and submit the
  completed form to the Department for approval to participate in Nebraska
  Medicaid.
003.02(B)
CONTACT LENS SERVICES.
Only providers whose licensure
  allows prescription, fitting, and supervision of adaptation, will be approved
  for payment of contact lenses.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 24 - VISUAL CARE SERVICES › Section 471-24-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
GENERAL REQUIREMENTS
004.01(A) Medical Necessity. Nebraska
  Medicaid incorporates the definition of medical necessity from 471 NAC 1 as is
  fully rewritten herein. Services and supplies that do not meet the 471 NAC 1
  definition of medical necessity are not covered.
004.01(B)
SERVICES PROVIDED FOR
  RECIPIENTS ENROLLED IN THE NEBRASKA MEDICAID MANAGED CARE PROGRAM.
See 471 NAC 1.
004.01(C)
EARLY AND PERIODIC, SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT)
  SERVICES.
See 471 NAC 33.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 24 - VISUAL CARE SERVICES › Section 471-24-005 - BILLING AND PAYMENT FOR VISUAL CARE SERVICES

Current through June 17, 2024
005.01
BILLING.
005.01(A)
GENERAL BILLING REQUIRMENTS.
Providers must comply
  with all applicable billing requirements codified in 471 NAC 3. In the event
  that billing requirements in 471 NAC 3 conflict with billing requirements
  outlined in this 471 NAC 24, the billing requirements in 471 NAC 24 will
  govern.
005.01(B)
SPECIFIC BILLING REQUIREMENTS.
005.01(B)(i)
BILLING
  REQUIRMENTS.
Providers must bill Nebraska Medicaid for visual care
  services on the appropriate claim form or electronic format.
005.01(B)(ii)
USUAL AND CUSTOMARY
  CHARGE,
The provider or their authorized agent must submit the
  provider's usual and customary charge for services rendered. The provider's
  total charge for services may not exceed the provider's usual and customary
  charge.
005.01(B)(iii)
NON-COVERED SERVICES.
If the provider furnishes items
  or services not covered by Nebraska Medicaid, on a private basis, the
  individual must pay the full charge of the items or services. The provider is
  prohibited from billing Nebraska Medicaid for any portion of the non-covered
  items or services.
005.01(B)(iv)
BILLING THE RECIPIENT FOR FRAMES.
Charges for frames
  purchased by a recipient on a private pay basis must include the associated
  fitting charge.
005.01(B)(v)
BILLING FOR LENSES.
005.01(B)(v)(1)
SCRATCH RESISTANT
  COATING.
The cost for the scratch; resistant coating must be
  included in the lens cost and is not billed under a separate procedure code.
  The laboratory invoice must indicate that the scratch resistant coating was
  provided. Nebraska Medicaid does not require that lenses with scratch resistant
  coating be warranted:
005.01(B)(v)(2)
BILLING THE
  RECIPIENT.
005.01(B)(v)(2)(a)
LENSES.
Charges for lens purchased by a recipient on a
  private pay basis must include the associated fitting charge.
005.01(B)(v)(2)(b)
SPECIAL LENS
  FEATURES AND LAB PROCEDURES
- If non-covered lens features or lab
  procedures other than non-covered tints are desired by recipients, they must be
  purchased on a private pay basis.
005.01(B)(v)(2)(c)
LENS
  TINTS.
The recipient can be billed for non-covered lens tints
  under the following conditions:
(i) The
  recipient has been notified by the provider in writing that Nebraska Medicaid
  will not cover the lens tint: and
(ii) The recipient voluntarily agrees to
  reimburse the provider for the lens tint on a private pay basis.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 25 - SCHOOL BASED SERVICES › Section 471-25-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern services provided in schools under the Medical
	 Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§
									68-901
	 to
	 68-991,
	 and Neb. Rev. Stat. §
									43-2511.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 25 - SCHOOL BASED SERVICES › Section 471-25-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
ACTIVITIES OF DAILY
  LIVING.
Self-care activities routinely performed daily for an
  individual's continued well-being, including mobility and transferring,
  dressing and grooming, bathing and personal hygiene, toileting, bladder care,
  and eating.
002.02
TRANSPORTATION.
Transportation paid by Medicaid for a
  student both to and from a Medicaid reimbursable service required by the
  student's Individual Education Plan (IEP) or Individualized Family Service Plan
  (IFSP).
002.03
OUTSIDE
  MEDICAL SERVICE.
A medical service received in a facility not
  located on the premises of the educational facility the student
  attends.
002.04
PROVIDER.
An enrolled Medicaid provider that is also a
  public school district, Education Services Unit (ESU), or approved
  cooperative.
002.05
SPECIALLY ADAPTED VEHICLE.
A vehicle equipped with
  adaptive devices to medically accommodate physical disabilities of passengers.
002.06
TRANSPORTATION
  AIDE.
An individual who assists with passenger needs and
  transportation accommodations required by a student's Individual Education Plan
  (IEP) or Individualized Family Service Plan (IFSP).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 25 - SCHOOL BASED SERVICES › Section 471-25-003 - PROVIDER REQUIREMENTS

Current through June 17, 2024
To participate in school-based services, a provider must comply with
	 all applicable provider participation requirements of 471 Nebraska
	 Administrative Code (NAC) Chapters 2 and 3, and this chapter. If any applicable
	 provider participation provision of 471 NAC Chapters 2 or 3 conflicts with any
	 requirement of this chapter, the requirement of this chapter governs. Each
	 person providing school-based services must be enrolled as an affiliated group
	 member under the billing provider identification, provide services in
	 compliance with any applicable requirements for licensure or certification,
	 provide services in compliance with any applicable chapters of 471 NAC, be age
	 19 or older, and be employed by or under contract with the
	 provider.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 25 - SCHOOL BASED SERVICES › Section 471-25-004 - DIRECT SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
GENERAL SERVICE REQUIREMENTS.
School-based services
  must be medically necessary to meet the specific and covered needs of a student
  and the student's family, if applicable, and be required by:
(A) A related service or supplementary aid or
  service in an Individual Education Program HER; or
(B) An early intervention service in an
  Individualized Family Service Plan (IFSP).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 25 - SCHOOL BASED SERVICES › Section 471-25-005 - INDIRECT SERVICES (NEBRASKA EDUCATION-BASED MEDICAID ADMINISTRATIVE CLAIMING)

Current through June 17, 2024
005.01
INDIRECT SERVICES.
Reimbursement for indirect services, such as outreach that supports
	 Medicaid services, are allowed if reasonable and necessary for the proper and
	 efficient administration of Medicaid and if allowable according to the Nebraska
	 Education-Based Medicaid Administrative Claiming (NEBMAC)
	 Guide.