reglab/statecodes huggingface dataset:
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 10 - HOSPITAL SERVICES › Section 471-10-006 - LIMITATIONS AND REQUIREMENTS FOR CERTAIN SERVICES

Current through June 17, 2024
006.01
PRIOR AUTHORIZATION PROCEDURES.
The physician must
  request prior authorization for these services in writing or the standard
  electronic Health Care Services Review: Request for Review and Response
  transaction (ASC X12N 278) prior to providing the service.
006.01(A)
REQUEST FOR ADDITIONAL
  EVALUATIONS.
The Department may request additional evaluations
  when the medical history for the request is questionable or when there is not
  sufficient information to support the requirements for authorization.
006.01(B)
PRIOR AUTHORIZATION
  APPROVAL/DENIAL PROCESS.
The prior authorization request review
  and determination must be completed by one or all of the following Department
  representatives:
(1) Medical
  Director;
(2) Designated Department
  Program Specialists; and
(3)
  Medical Consultants for the Department for certain specialties.
006.01(C)
VERBAL
  AUTHORIZATION PROCEDURES.
The Department may issue a verbal
  authorization when circumstances are of an emergency nature or urgent to the
  extent that a delay would place the client at risk of receiving medical care.
  When a verbal authorization is granted, a written request or electronic request
  using the standard electronic Health Care Services Review: Request for Review
  and Response transaction (ASC X12N 278) must be submitted within 14 days of the
  verbal authorization.
006.01(D)
BILLING AND PAYMENT REQUIREMENTS.
Claims submitted to
  the Department for services defined as requiring prior authorization will not
  be paid without written or electronic approval from the Department. A copy of
  the approval letter or notification of authorization issued by the Department
  must be submitted with all claims related to the procedure or service
  authorized.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 10 - HOSPITAL SERVICES › Section 471-10-008 - MEDICAL RECORDS

Current through June 17, 2024
The hospital must have a medical record service that has administrative
	 responsibility for medical records. A medical record must be maintained for
	 every individual evaluated or treated in the hospital. For the purposes of 471
	 NAC 10, the term "medical record" includes electronic health records
	 (EHR).
008.01
ORGANIZATION
  AND STAFFING.
The organization of the medical record service must
  be appropriate to the scope and complexity of the services performed. The
  hospital must employ adequate personnel to ensure prompt completion, filing,
  and retrieval of records.
008.01(A) The
  hospital must maintain a medical record for each inpatient and outpatient.
  Medical records must be accurately written, including accurate entry of
  electronic health records (EHR) into computer systems, promptly completed,
  properly filed and retained, and accessible. The hospital must use a system of
  author identification and record maintenance that ensures the integrity of the
  authentication and protects the security of all record entries.
008.01(B) Medical records must be retained in
  their original or legally reproduced form for a period of five years. The
  hospital must have a system of coding and indexing medical records. The system
  must allow for timely retrieval by diagnosis and procedure, in order to support
  medical care evaluation studies.
008.01(C) The hospital must have a procedure
  for ensuring the confidentiality of patient records. Information from or copies
  of records may be released only to authorized individuals, and the hospital
  must ensure that unauthorized individuals cannot gain access to or alter
  patient records. Original medical records must be released by the hospital only
  in accordance with federal or state laws, court orders, or subpoenas.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 11 - INDIAN HEALTH SERVICE (IHS) FACILITIES › Section 471-11-001 - Definitions

Current through June 17, 2024
Encounter: A face-to-face visit, including telehealth services provided
	 in accordance with 471 NAC
	 1-006, between a health care
	 professional and an individual eligible for the provision of medically
	 necessary Medicaid-defined services in an IHS or Tribal (638) facility within a
	 24-hour period ending at midnight, as documented in the client's medical
	 record.
Indian or Indians: An individual who meets any of the definitions in
	 25
	 U.S.C. §§
										1603(3),
	 1603(13),
	 and
	 1679,
	 or who has been determined eligible, as an Indian, pursuant to
	 42
	 C.F.R. §§
										136.1 and
	 136.12
	 or Title V of the Indian Health Care Improvement Act, to receive health care
	 services from Indian health care providers (IHS, an Indian Tribe, Tribal
	 Organization, or Urban Indian Organization - I/T/U) or through referral under
	 Contract Health Services (
	 25
	 U.S.C §
										1603(5)
	 ).
Indian Health Service (IHS): An agency within the United State
	 Department of Health and Human Services, which is responsible for providing
	 federal health services to American Indians and Alaska Natives.
IHS Provider: A health care program, including contract health services
	 ( 25
	 U.S.C §
										1603(5) ),
	 operated by the Indian Health Service or by an Indian Tribe, Tribal
	 Organization, or Urban Indian Organization as those terms are defined
	 25
	 U.S.C. §
										1603. This includes Hospitals,
	 Hospital Based Facilities, Pharmacies and outpatient clinics.
IHS Supplier: A freestanding (non-hospital based) entity that furnishes
	 durable medical equipment, prosthetics, orthotics, supplies, and parenteral or
	 enteral nutrition.
IHS Physician or Practitioner: Physician and non-physician
	 practitioners billing for services under Medicaid.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 11 - INDIAN HEALTH SERVICE (IHS) FACILITIES › Section 471-11-003 - SERVICE REQUIREMENTS

Current through June 17, 2024
NMAP reimburses IHS facilities for inpatient and outpatient services
	 at the Medicare/Medicaid rates established by the federal Department of Health
	 and Human Services (HHS).
Rate changes are effective the first day of the month following the
	 Department's receipt of the Medicare Interim Rate Notice. Because specific
	 Medicare/Medicaid rates are used and there is 100 percent federal match of
	 these costs, NMAP will not make an end-of-year settlement for Indian Health
	 Service facilities.
003.01 General
  Requirements
11-003.01A Eligibility:
  Medically necessary services will be made available to any Indian, as that term
  is defined herein, who is also determined to be eligible for Medicaid in
  accordance with Title 477 of the Nebraska Administrative Code.
11-003.01B Services Provided for Clients
  Enrolled in the Nebraska Medicaid Managed Care Program: See 471 NAC
  1-002.01.
11-003.01C HEALTH CHECK
  (EPSDT) Treatment Services: See 471 NAC Chapter 33.
11-003.01D Copayments / Cost Sharing:
  American Indians or Alaskan Natives who are eligible for, and have received,
  Medicaid covered services from an IHS or Tribal (638) facility shall be exempt
  from all copayment and cost sharing obligations.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 12 - NURSING FACILITY REGULATIONS › Section 471-12-001 - 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. (the Medical Assistance Act).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 12 - NURSING FACILITY REGULATIONS › Section 471-12-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
ACUTE MEDICAL
  HOSPITAL.
An institution which:
(A) Is licensed or formally approved as a
  hospital by an officially designated authority for State
  standard-setting;
(B) Meets the
  requirements for participation in Medicare as a hospital; and
(C) Has in effect a utilization review plan,
  applicable to all Medicaid patients, that meets the requirements of 42 Code of
  Federal Regulations (CFR) 482.30.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 12 - NURSING FACILITY REGULATIONS › Section 471-12-003 - GENERAL PROVIDER REQUIREMENTS

Current through June 17, 2024
To participate in Medicaid, providers of nursing facility (NF) services
	 must comply with all applicable provider participation requirements codified in
	 471 NAC 2 and 3. In the event that provider participation requirements in 471
	 NAC 2 or 3 conflict with requirements outlined in this 471 NAC 12, the
	 individual provider participation requirements in 471 NAC 12 will
	 govern.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 12 - NURSING FACILITY REGULATIONS › Section 471-12-004 - GENERAL SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
MEDICAL NECESSITY.
Nursing facility (NF) clients must
  meet the medical necessity requirements in 471 NAC 1, and each client must be
  determined to meet nursing facility level of care (NF LOC) as specified in this
  chapter.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 12 - NURSING FACILITY REGULATIONS › Section 471-12-005 - GENERAL BILLING AND PAYMENT FOR NURSING FACILITY (NF) SERVICES

Current through June 17, 2024
005.01
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 12, the individual billing requirements in 471 NAC 12 will
  govern.
005.02
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 that individual payment
  regulations in 471 NAC 3 conflict with payment regulations outlined in this 471
  NAC 12, the individual payment regulations in 471 NAC 12 will govern.
005.03
GENERAL COST REPORTING
  REQUIREMENTS.
The Department may require providers to submit
  certain cost reports for the calculation of reimbursement rates. Providers must
  submit such cost reports as requested and in the manner specified by the
  Department.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 12 - NURSING FACILITY REGULATIONS › Section 471-12-006 - PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR)

Current through June 17, 2024
When an individual requests admission to or continuous residence in a
	 Medicaid-certified nursing facility (NF), the facility must implement the
	 preadmission screening and resident review (PASRR) as defined in this chapter.
	 An individual who has an indication or diagnosis of serious mental illness,
	 intellectual disability or a related condition, or a dual diagnosis may be
	 admitted to a nursing facility (NF) or continue to reside in a nursing facility
	 (NF) only when the individual is determined to be appropriate for nursing
	 facility (NF) services through the preadmission screening and resident review
	 (PASRR). The preadmission screening and resident review (PASRR) provides the
	 following to an individual with a diagnosis or indication of serious mental
	 illness, intellectual disability or a related condition, or a dual
	 diagnosis:
(A) A determination whether
  the individual has serious mental illness, intellectual disability or a related
  condition, or a dual diagnosis;
(B)
  A determination whether the level of services provided by a nursing facility
  (NF) is appropriate to meet the individual's needs; and
(C) A recommendation for services that
  addresses the individual's needs in a nursing facility (NF) or in an
  alternative placement.
006.01
PURPOSE OF THE PREADMISSION SCREENING AND RESIDENT REVIEW
  (PASRR).
The purpose of the preadmission screening and resident
  review (PASRR) is to:
(A) Determine the
  appropriateness of nursing facility (NF) care for persons with serious mental
  illness, intellectual disability or a related condition, or a dual
  diagnosis;
(B) Prevent the
  placement of individuals with serious mental illness, intellectual disability
  or a related condition, or a dual diagnosis in nursing facilities unless their
  medical needs clearly indicate that they require the level of care (LOC)
  provided by a nursing facility (NF);
(C) Coordinate services needs among the
  health care industry and the mental health and developmental disability
  systems;
(D) Comply with state and
  federal requirements mandating an evaluation process that facilitates the
  nursing facility's (NF) responsibility to provide services and activities to
  attain and maintain the highest practical physical, mental, and psychosocial
  wellbeing of each resident; and
(E)
  Assist with the placement of persons found inappropriate for nursing facility
  (NF) care into more appropriate, least restrictive services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 12 - NURSING FACILITY REGULATIONS › Section 471-12-007 - NURSING FACILITY (NF) SERVICES

Current through June 17, 2024
007.01
STANDARDS FOR PARTICIPATION FOR NURSING FACILITIES.
The nursing facility (NF) must meet:
(A) The
  Nebraska nursing home licensure, and Medicare and Medicaid certification
  standards as required by state statutes and 42 CFR 483, Subpart B, or if
  located outside of Nebraska, similar standards in that state;
(B) The facility type, program and
  operational definitions; and
(C)
  The definition of a nursing facility (NF) as defined in this chapter, and in
  section 1919 of the Social Security Act.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 12 - NURSING FACILITY REGULATIONS › Section 471-12-009 - SERVICES FOR LONG TERM CARE CLIENTS WITH SPECIAL NEEDS

Current through June 17, 2024
009.01
LONG TERM CARE CLIENTS
  WITH SPECIAL NEEDS.
Long term care clients with special needs
  means those whose medical or nursing needs are complex or intensive and are
  above the usual level of capabilities of staff and exceed services ordinarily
  provided in a nursing facility.
009.01(A)
VENTILATOR-DEPENDENT CLIENTS.
These clients are
  dependent on mechanical ventilation to continue life and require intensive or
  complex medical services on an on-going basis. The facility shall provide
  24-hour registered nurse nursing coverage.
009.01(A)(i)
CRITERIA FOR
  CARE.
The client must:
(1)
  Require intermittent, but not less than 10 hours in a 24-hour period, or
  continuous ventilator support. They are dependent on mechanical ventilation to
  sustain life, or is in the process of being weaned from mechanical ventilation.
  This does not include individuals using continuous positive airway pressure
  (C-PAP) or Bi-level positive airway pressure (Bi-PAP) nasally. Patients
  requiring use of Bi-level positive airway pressure via a tracheostomy will be
  considered on a case-by-case basis;
(2) Be medically stable and not require
  intensive acute care services;
(3)
  Have care needs which require multi-disciplinary care;
(4) Require daily respiratory therapy
  intervention or modality support; and
(5) Have needs that cannot be met at a lesser
  level of care.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 12 - NURSING FACILITY REGULATIONS › Section 471-12-010 - MEDICAID HOSPICE BENEFIT

Current through June 17, 2024
010.01
STANDARDS FOR PARTICIPATION.
To participate in
  Medicaid, a hospice must be a public agency or private organization or a
  subdivision of either that is primarily engaged in providing care to terminally
  ill individuals and is certified for participation in Medicare as a hospice.
010.01(A)
PROVIDER
  ENROLLMENT.
To complete the provider enrollment process, the
  hospice must meet the following conditions:
(i) The hospice must have a signed, written
  and non-resident-specific contract with each certified nursing facility (NF) or
  intermediate care facility for individuals with developmental disabilities
  (ICF/DD); and
(ii) The hospice must
  complete and submit a Medicaid provider agreement in entirety to Medicaid for
  each contracted nursing facility (NF) or intermediate care facility for
  individuals with developmental disabilities (ICF/DD).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 12 - NURSING FACILITY REGULATIONS › Section 471-12-011 - CIVIL MONEY PENALTY (CMP)

Current through June 17, 2024
011.01
COLLECTION AND USE OF CIVIL MONEY PENALTY (CMP) FUNDS.
The Nebraska Civil Money Penalty (CMP) Program is administered by the
  Department in accordance with Section 1919(h)(3)(C)(ii)(IV)(ff) of the Social
  Security Act,
  42 CFR 488.400
  through
  488.456
  and Nebraska Revised State Statutes
  71-2097
  to
  71-20,101.
011.01(A)
ASSESSMENT OF
  PENALTY.
The Division of Public Health of the Department of Health
  and Human Services is authorized to act as the survey and certification agency
  for the Medicaid program pursuant to Neb. Rev. Stat. 81-604.03. The Division of
  Public Health notifies the Department of any violation by a nursing facility
  (NF), as defined in Neb. Rev. Stat. 71-2097. Civil penalties will be determined
  pursuant to Neb. Rev. Stat. 712097 to 71-20,101. Upon the recommendation of the
  Civil Money Penalty (CMP), the Department issues a certified letter to the
  provider according to
  42 CFR
  488.434.
011.01(B)
APPEAL.
See 471 NAC 2.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 12 - NURSING FACILITY REGULATIONS › Section 471-12-012 - NURSE AIDES IN NURSING FACILITIES

Current through June 17, 2024
012.01
GENERAL RULE.
An individual may be employed by a
  certified facility as a nurse aide only if all of the following requirements
  have been met:
(A) That individual is
  competent to provide nursing and nursing-related services;
(B) The nurse aide has met the training and
  competency requirements found at
  42 CFR
  483.75, 150 and 154, or that individual has
  been deemed or determined competent as provided in
  42 CFR
  483.150;
(C) The nurse aide has met the requirements
  set out in Neb. Rev. Stat. §
										71-6038
  and 6039; and
(D) The nurse aide
  has not:
(i) Been found guilty of abusing,
  neglecting, or mistreating residents by a court of law; or
(ii) Had a finding entered into the State
  nurse aide registry concerning abuse, neglect, or mistreatment of residents or
  misappropriation of their property under the provisions of this
  chapter.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 14 - OCCUPATIONAL AND PHYSICAL THERAPY SERVICES › Section 471-14-001 - 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 §§
									68-901
	 et seq.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 14 - OCCUPATIONAL AND PHYSICAL THERAPY SERVICES › Section 471-14-002 - DEFINITIONS

Current through June 17, 2024
002.01
INTERVENTION.
A therapeutic procedure defined by the Current Procedural Terminology (CPT)
  manual of the American Medical Association.
002.02
MOBILIZATION OR MANUAL
  THERAPY.
A group of techniques comprising a continuum of skilled
  passive movements to the joints or related soft tissues, or both, throughout
  the normal physiological range of motion that are applied at varying speeds and
  amplitudes, without limitation.
002.03
OCCUPATIONAL
  THERAPIST.
A person holding a current license to practice
  occupational therapy.
002.04
OCCUPATIONAL THERAPY.
The use of purposeful activity
  with individuals who are limited by physical injury or illness, psychosocial
  dysfunction, developmental or learning disabilities, or the process of aging in
  order to maximize independent function, prevent further disability, and achieve
  and maintain health and productivity. Occupational therapy encompasses
  evaluation, treatment, and consultation and may include:
(A) Remediation or restoration of performance
  abilities that are limited due to impairment in biological, physiological,
  psychological, or neurological processes;
(B) Adaptation of task, process, or the
  environment, or the teaching of compensatory techniques, in order to enhance
  performance;
(C) Disability
  prevention methods and techniques which facilitate the development or safe
  application of performance skills; and
(D) Health promotion strategies and practices
  which enhance performance abilities.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 14 - OCCUPATIONAL AND PHYSICAL THERAPY SERVICES › Section 471-14-003 - PROVIDER REQUIREMENTS

Current through June 17, 2024
003.01
GENERAL PROVIDER REQUIREMENTS.
To participate in
  Nebraska Medicaid, providers of physical therapy and occupational therapy
  services must comply with all applicable provider participation requirements
  codified in 471 Nebraska Administrative Code (NAC) 2 and 3. In the event that
  provider participation requirements in 471 NAC 2 or 3 conflict with
  requirements outlined in this 471 NAC 14, the individual provider participation
  requirements in 471 NAC 14 will govern.
003.02
SPECIFIC PROVIDER
  REQUIREMENTS.
003.02(A)
LICENSED OCCUPATIONAL THERAPIST (OT) ASSISTANTS AND CERTIFIED
  PHYSICAL THERAPIST (PT) ASSISTANTS.
The Department does not enroll
  occupational therapy assistants (OTA) or physical therapy assistants (PTA) as
  providers. Services provided by an occupational therapy assistant (OTA) are
  covered by the Department when all requirements of 172 NAC 114 are met.
  Services provided by a physical therapy assistant (PTA) are covered by the
  Department when all requirements of 172 NAC 137 are met.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 14 - OCCUPATIONAL AND PHYSICAL THERAPY SERVICES › Section 471-14-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
GENERAL SERVICE REQUIREMENTS.
004.01(A)
MEDICAL
  NECESSITY.
The Department incorporates the medical necessity
  requirements outlined in 471 NAC 1 as if fully rewritten herein. Services and
  supplies that do not meet the requirements in 471 NAC 1 are not
  covered.
004.01(B)
SERVICE CRITERIA.
The Department covers occupational
  therapy (OT) or physical therapy (PT) services when the following criteria are
  met. The service must be:
(i) An
  evaluation;
(ii) Restorative
  therapy with a medically appropriate expectation that the client's condition
  will improve significantly within a reasonable period of time; or
(iii) For physical therapy (PT) services
  only, recommended in a Department-approved Individual Program Plan (IPP), and
  the client is receiving services through one of the following waiver programs:
(1) Developmental Disabilities (DD) Adult
  Comprehensive Services Waiver;
(2)
  Developmental Disabilities (DD) Adult Residential Services Waiver;
(3) Developmental Disabilities (DD) Adult Day
  Services Waiver;
(4) Community
  Supports Waiver; or
(5) Home and
  Community Based Services Waiver for Children with Developmental Disabilities
  and their Families.
004.01(C)
SERVICES FOR
  INDIVIDUALS AGE 21 AND OLDER.
For clients age 21 and older, the
  Department covers a combined total of 60 therapy sessions per fiscal year (July
  1 through June 30). The combined total of 60 therapy sessions per fiscal year
  includes all occupational therapy (OT), physical therapy (PT), and speech
  therapy sessions provided to the client.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 14 - OCCUPATIONAL AND PHYSICAL THERAPY SERVICES › Section 471-14-005 - BILLING AND PAYMENT FOR OCCUPATIONAL THERAPY OR PHYSICAL THERAPY 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 14, the individual billing requirements
  in 471 NAC 14 will govern.
005.01(B)
SPECIFIC BILLING
  REQUIREMENTS.
005.01(B)(i)
BILLING INSTRUCTIONS.
The provider must bill the
  Department using the appropriate claim form or electronic format.
005.01(B)(ii)
USUAL AND CUSTOMARY
  CHARGE.
The provider or the provider's authorized agent must
  submit the provider's usual and customary charge for each procedure code listed
  on the claim. Healthcare Common Procedure Coding System (HCPCS) procedure codes
  used by Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule.
005.01(B)(iii)
MEDICAL
  NECESSITY DOCUMENTATION.
The provider must provide the following
  information when submitting a claim for occupational therapy (OT) or physical
  therapy (PT) services:
(1) Date of illness or
  injury onset;
(2) Date occupational
  therapy or physical therapy plan established;
(3) Date occupational therapy or physical
  therapy started; and
(4) Number of
  occupational therapy or physical therapy visits from onset.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 15 - PERSONAL ASSISTANCE SERVICES › Section 471-15-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
Medicaid personal assistance services are defined in federal
	 regulations at 42 Code of Federal Regulations (CFR) 440.167, and are an
	 optional Medicaid benefit. Personal assistance services are provided to persons
	 with disabilities and chronic conditions of all ages to enable them to
	 accomplish tasks they would normally do for themselves if they did not have a
	 disability. Personal assistance services activities are limited to those
	 activities that are required to maintain the client's health and safety. The
	 regulations govern the services provided under Nebraska's Medicaid program as
	 defined by Nebraska Revised Statue (Neb. Rev. Stat.) §§
									68-901
	 et seq.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 15 - PERSONAL ASSISTANCE SERVICES › Section 471-15-002 - DEFINITION OF TERMS

Current through June 17, 2024
The following definitions apply:
002.01
CARETAKER.
Defined in Neb. Rev. Stat. §
									38-2219
  of the Nurse Practice Act, which explains health maintenance activities, to
  mean a person who is:
(A) Directly and
  personally involved in providing care for a minor child or incompetent adult;
  and
(B) The parent, foster parent,
  family member, friend, or legal guardian of such minor child or incompetent
  adult.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 15 - PERSONAL ASSISTANCE SERVICES › Section 471-15-005 - BILLING AND PAYMENT FOR PERSONAL ASSISTANCE SERVICES

Current through June 17, 2024
005.01
BILLING.
005.01(A)
GENERAL BILLING
  REQUIREMENTS.
Providers will comply with all applicable billing
  requirements located in 471 NAC 3, and with all applicable billing requirements
  for the Electronic Visit Verification (EVV) system.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 15 - PERSONAL ASSISTANCE SERVICES › Section 471-15-006 - CLIENT RIGHTS AND RESPONSIBILITIES

Current through June 17, 2024
006.01
CLIENT RIGHTS.
Clients, or if the clients not able to
  exercise these rights, a designated, responsible party who is able to perform
  these functions for the client, who are found to be eligible for personal
  assistance services have the right to:
(A)
  Identify their service needs;
(B)
  Determine their preferred approved provider, which may include selecting from a
  Medicaid enrolled list of providers;
(C) Identify a possible provider who meets
  the minimum qualifications as described in this chapter;
(D) Direct their personal assistance
  services;
(E) Receive services
  according to the service plan, free from risk of harm or exploitation,
  including physical and verbal abuse, theft and misuse of household belongings,
  personal funds, prescriptions or other medical supplies; and
(F) Dismiss a provider if not satisfied with
  the provision of services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
The regulations govern the services provided under Nebraska's Medicaid
	 program as defined by the Medical Assistance Act (Nebraska Revised Statute
	 68-901
	 et seq).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-002 - DRUG UTILIZATION REVIEW

Current through June 17, 2024
As a condition of participation, the provider is required to:
(A) Provide prospective drug utilization
  review before dispensing each prescription. This includes screening for:
(i) Therapeutic duplication:
(ii) Drug disease
  contraindications:
(iii) Drug
  interactions:
(iv) Incorrect dosage
  or duration:
(v) Drug allergies:
  and
(vi) Clinical abuse and
  misuse:
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-003 - COVERED SERVICES

Current through June 17, 2024
Nebraska Medicaid covers outpatient drugs in accordance with the
	 Omnibus Budget Reconciliation Act of 1990 including:
(A) Legend drugs;
(B) Compounded prescriptions: and
(C) Over-the-counter drugs indicated as
  covered on the Nebraska Point of Purchase System or listed on the Nebraska
  Medicaid Pharmacy Program website.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-004 - COMPOUNDED PRESCRIPTIONS

Current through June 17, 2024
A compounded prescription is a mixture of ingredients which the
	 provider prepares in the pharmacy.
004.01
REIMBURSEMENT FOR
  COMPOUNDED PRESCRIPTIONS.
Reimbursement for compounded
  prescriptions will be limited to those ingredients which are indicated as
  covered on the Nebraska Point of Purchase System or listed on the Nebraska
  Medicaid Pharmacy Program website. Any mixture of drugs which results in a
  commercially available over-the-counter preparation is not considered a
  compounded prescription.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-005 - OVER-THE-COUNTER DRUGS

Current through June 17, 2024
Covered drugs include only over-the-counter drugs indicated as covered
	 on the Nebraska Point of Purchase System or those listed on the Nebraska
	 Medicaid Pharmacy Program website. Over-the-counter drugs must be prescribed by
	 a licensed practitioner.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-006 - TOBACCO CESSATION COUNSELING

Current through June 17, 2024
In addition to a physician or mid-level practitioner, only a licensed
	 pharmacist, meeting Department conditions of participation listed above as a
	 Tobacco Cessation Counselor, may provide tobacco cessation counseling.
006.01
TOBACCO CESSATION
  COUNSELING CONDITIONS OF PARTICIPATION.
As a condition of
  participation as a Tobacco Cessation Counselor, the provider must:
(A) Be a licensed pharmacist:
(B) Complete a Department-approved tobacco
  cessation counselor training;
(C)
  Maintain current training as a Tobacco Cessation counselor as required by the
  Department;
(D) Complete and sign a
  new provider agreement, indicating the employing pharmacy as the "pay to"
  provider, and submit proof of completing the Department-required training as
  part of the provider agreement completion process, or upon request by the
  Department:
(E) Provide Tobacco
  Cessation counseling which is separate and distinct from the prospective drug
  utilization review required in this chapter and is not related to the
  dispensing of any drug product; and
(F) Provide feedback to the physician or
  mid-level practitioner who ordered the services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-007 - PRESCRIPTION REFILLS

Current through June 17, 2024
Prescription refills must be performed and recorded in a manner
	 consistent with existing State and Federal laws, rules, and regulations.
	 Automatic refills are not allowed. All prescription refills must be initiated
	 by a request from the prescriber, client, or an authorized representative. If
	 the client is residing in a facility, a nurse or other authorized agent of the
	 facility pursuant to a valid prescriber's order may initiate the request for
	 refill.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-008 - NON-COVERED DRUGS

Current through June 17, 2024
Payment by Nebraska Medicaid will not be approved for:
(A) Requests for Quantities not in compliance
  with the requirements of this chapter:
(B) Experimental drugs or drugs not approved
  by the Food and Drug Administration:
(C) Drugs or other items not prescribed for a
  medically accepted indication:
(D)
  Drugs or other items prescribed or recommended for weight control or appetite
  suppression:
(E) Any alcoholic
  beverage;
(F) Drug Efficacy Study
  Implementation Program drugs identified as Less Than Effective or identical.
  Related, or Similar with an indicator value assigned by the Food and Drug
  Administration of either 5 or 6;
(G) Personal care items;
(H) Medical supplies and certain drugs for
  nursing facility and intermediate care facility patients:
(I) Over-the-counter drugs not listed on the
  Nebraska Medicaid Pharmacy Program website:
(J) Drugs or other items used for cosmetic
  purposes or hair growth:
(K) Baby
  foods, milk substitutes, or metabolic agents normally supplied by the
  Department:
(L) Drugs distributed
  or manufactured by certain drug manufacturers or labelers which have not agreed
  to participate in the drug rebate program:
(M) Products used to promote
  fertility;
(N) Medications
  dispensed as partial month fills for nursing facility or group home residents
  when dispensed by more than one pharmacy;
(O) Medications dispensed to replace products
  which have been recalled by the drug manufacturer:
(P) Drugs, or other products of manufacturers
  or labelers identifiable as non-covered on the Nebraska Point of Purchase
  System or on the Nebraska Medicaid Pharmacy Program website:
(Q) Drugs, classes of drugs, or therapeutic
  categories of drugs which are Medicare Part D Drugs and Medicare Part D Covered
  supplies or equipment, for all individuals eligible for benefits under Medicare
  Part D, whether or not the individual is enrolled in a Medicare Part D
  Plan;
(R) Drugs or classes of drugs
  approved by the Federal Food and Drug Administration for treatment of sexual or
  erectile dysfunction, or drugs or classes of drugs which are being used for the
  treatment of sexual or erectile dysfunction. Drugs or classes of drugs which
  are approved by the Federal Food and Drug Administration for treatment of
  sexual or erectile dysfunction and for conditions other than treatment of
  sexual or erectile dysfunction, and are prescribed for those other conditions
  may be covered, but Nebraska Medicaid may require prior authorization:
  and
(S) Automatic
  refills.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-009 - LIMITATIONS AND REQUIREMENTS FOR CERTAIN DRUGS

Current through June 17, 2024
009.01
PRIOR AUTHORIZATION.
The Department requires
  authorization be granted prior to payment for certain drugs. Should a
  practitioner dispense a prescription prior to the actual authorization, he or
  she takes a business risk payment for the prescription can be denied.
009.01(A)
PRIOR AUTHORIZATION
  RESPONSE.
The Nebraska Point of Purchase contractor or the
  Department will respond to any request for prior authorization within 24 hours
  of receipt of the request.
009.01(B)
APPROVAL
  DECISION.
The Nebraska Point of Purchase contractor or the
  Department will notify the provider prescribing the drug or the pharmacy
  dispensing the drug if the authorization has been granted, the eligible dates
  of the authorization, and the identification of the provider who requested the
  authorization. The prior authorization is given for the drug, the client, and
  the prior authorization dates.
009.01(C)
DENIAL
  DECISION.
The Nebraska Point of Purchase contractor or the
  Department will notify the provider prescribing the drug or the pharmacy
  dispensing the drug if coverage is denied.
009.01(D)
EMERGENCY
  DECISION.
The Nebraska Point of Purchase contractor or the
  Department will authorize dispensing up to a 72-hour supply of a covered
  outpatient prescribed medication for cases meeting the definition of a medical
  emergency as outlined in chapter two of this title.
009.01(E)
UNKNOWN
  DECISION.
If the provider prescribing the drug or the pharmacy
  dispensing the drug has not received an authorization from the Nebraska Point
  of Purchase contractor or the Department, payment may be denied.
009.01(F)
VERIFYING STATUS OF
  REQUESTS.
The pharmacy can verify the status of prior
  authorization requests for prescriptions by submitting a claim via the Nebraska
  Point of Purchase System, if the prior authorization request has not been
  approved, the pharmacy may contact the Nebraska Point of Purchase contractor or
  the Department for prior authorization.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-010 - DRUG UTILIZATION REVIEW

Current through June 17, 2024
The Department is authorized by federal statute to conduct a Drug
	 Utilization Review program. The Drug Utilization Review program consists of
	 prospective drug review, retrospective drug review, the application of explicit
	 predetermined standards, and an educational program. The purpose of the Drug
	 Utilization Review program is to improve the quality of pharmaceutical care by
	 ensuring prescriptions are appropriate and medically necessary and not likely
	 to result in adverse medical results.
010.01
DRUG UTILIZATION REVIEW
  BOARD.
The Department or the Department's contractor utilizes a
  Drug Utilization Review Board to review and analyze available clinical and
  economic data. The Drug Utilization Review Board reviews and makes
  recommendations based on predetermined standards submitted to them by the
  Department or the Department's contractor and, in concert with retrospective
  review of claims data, makes recommendations for educational interventions,
  prospective Drug Utilization Review, and the prior authorization
  process.
010.02
REVIEW
  FOR PRIOR AUTHORIZATION RECOMMENDATION.
The Drug Use Review Board
  will, upon the Department's request, review drugs or classes of drugs and make
  recommendations to the Department regarding drugs or classes of drugs for prior
  authorization. The Department makes the final decision on which drugs or
  classes of drugs will require prior authorization. For those drugs which will
  require prior authorization, the Drug utilization Review Board will develop and
  recommend prior authorization criteria to the Department. The Department may
  accept, reject, or modify the recommended criteria. The Department will
  communicate information related to prior authorization criteria on the Nebraska
  Medicaid Pharmacy Program website. The Drug Utilization Review Board will
  review existing prior authorization criteria annually.
010.03
MANUFACTURER REQUESTS FOR
  DRUG REVIEW.
The manufacturer or any interested party may request
  a drug or class of drugs on prior authorization be placed on the agenda of a
  Drug Utilization Review board meeting, but no drug or class of drugs will be
  placed on the Drug Utilization Review agenda more than once every 12 months
  without the consent of the Drug Utilization Review director, in consultation
  with the Department's Pharmacy Consultant. The manufacturer of the drug may
  request the Drug Utilization Review director waive the 30-day notification rule
  when asking to have its product placed on the agenda.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-012 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPEMENT

Current through June 17, 2024
Any medical supply or durable medical equipment indicated as covered
	 on the Nebraska Point of Purchase System or on the Nebraska Medicaid Pharmacy
	 Program website is covered as a pharmacy service under this
	 chapter.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-013 - QUANTITY LIMITATIONS

Current through June 17, 2024
The Department imposes the following quantity limitations on certain
	 drugs.
013.01
QUANTITIES
  NOT ALLOWED.
Payment from Nebraska Medicaid will not be approved
  for:
(A) More than a three month supply of
  any maintenance medication:
(B)
  More than a one month supply of any controlled substance: and
(C) More than a one month supply of any
  injectable medication except insulin and those injectable drugs with a duration
  of greater than one month from one dose.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-014 - UTILIZATION

Current through June 17, 2024
Since it is the pharmacist's professional responsibility to ascertain
	 drugs are being utilized according to the prescriber's directions and no abuse
	 or overuse exists, the Department will not reimburse pharmacists for
	 prescriptions which demonstrate a lack of this professional obligation.
	 Providers are required to maintain patient record systems or other adequate
	 records to prevent these errors in dispensing. The Department's professional
	 staff is responsible for determining whether a claim violates the Department's
	 regulations. The Nebraska Point of Purchase system will identify drug claims
	 when potential overuse exists, and these claims will be denied
014.01
TOBACCO
  CESSATION.
Medicaid covers tobacco cessation services as
  practitioner and pharmacy services under the following conditions:
(A) Tobacco cessation counseling visits with
  an enrolled medical provider or pharmacist tobacco cessation counselor may be a
  combination of intermediate or intensive tobacco cessation counseling
  visits;
(B) Tobacco cessation
  products are covered by Medicaid as a pharmacy service for those clients
  meeting Federal Food and Drug Administration approved dosing and age guidelines
  who require this particular assistance. Tobacco cessation counseling provided
  by a Tobacco Cessation counselor must be ordered by the physician or mid-level
  practitioner: and
(C) Nebraska
  Tobacco Free Quitline: In conjunction with tobacco cessation products,
  recipients are encouraged to be enrolled in and active with the Nebraska
  Tobacco Free Quitline. Referral to the Quitline may be made by a medical
  professional or a self-referral. Recipient access to the Nebraska Tobacco Free
  Quitiine is unlimited.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-015 - PAYMENT FOR PHARMACY SERVICES

Current through June 17, 2024
015.01
PROFESSIONAL DISPENSING FEES.
015.01(A)
DISPENSING
  FEE,
The fee-for-service professional dispensing fee will be
  assigned to each claim payment based on the lesser of methodology described
  below.
015.01(B)
DISPENSING PHYSICIANS.
The Department assigns a
  professional dispensing fee to a dispensing physician only when there is no
  pharmacy within a 25-mile radius of the physician's place of
  practice.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 16 - PHARMACY SERVICES › Section 471-16-016 - BILLING REQUIREMENTS

Current through June 17, 2024
016.01
DRUG CLAIMS.
Claims for pharmacy services must meet
  the requirements listed in the Nebraska Point of Purchase System user's manual.
  The same standards apply to non-Point of Purchase system claims.
016.02
MEDICAL SUPPLIES AND
  DURABLE MEDICAL EQUIPMENT CLAIMS.
Providers must bill
  electronically using the standard Health Care Claim: Professional transaction
  or the Health Insurance Claim Form to submit claims for medical supplies and
  durable medical equipment unless otherwise stipulated.
016.03
ELECTRONIC MEDIA CLAIM
  REQUIREMENTS.
While the Department utilizes the Nebraska Point of
  Purchase System, providers are responsible for any errors, omissions, or
  inappropriate billings submitted by themselves or on their behalf by billing
  agents. The submission of any electronic media claim for reimbursement by the
  provider or by an approved company or organization on behalf of an approved
  provider constitutes certification of:
(A)
  The services or items for which payment is claimed were provided in compliance
  with the provisions of Title VI of the Civil Rights Act of 1964 and section 504
  of the Rehabilitation Act of 1973:
(B) The amounts claimed are in accordance
  with the Department's regulations, and no additional charge, other than
  Medicaid copayment, has been or will be claimed:
(C) Each service is documented and the
  documentation is open to audit by the Department or its agents: and
(D) The charge does not exceed the pharmacy's
  usual and customary charge to the general public.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 18 - PHYSICIANS' SERVICES › Section 471-18-001 - 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 §§
									68-901
	 et seq.