reglab/statecodes huggingface dataset:
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 2 - PROVIDER PARTICIPATION › Section 471-2-005 - ADMINISTRATIVE SANCTIONS

Current through June 17, 2024
005.01
REASONS FOR SANCTIONS.
The Department may, in its discretion, deny
  enrollment or sanction a provider for any of the following reasons:
(1) Improper billing and claims payment
  practices including, but not limited to:
(i)
  Presenting, or causing to be presented, any false or fraudulent claim for goods
  or services or merchandise for payment;
(ii) Submitting, or causing to be submitted,
  false information for the purpose of obtaining greater payment than that to
  which the provider is legally entitled;
(iii) Billing in excess of the usual and
  customary charges;
(iv) Presenting
  a claim, billing, or causing a claim to be presented for payment for services
  not rendered, including "no-shows";
(v) Submitting duplicate bills, including
  billing Medicaid twice for the same service, or billing both Medicaid and
  another insurer or government program;
(vi) Billing before the goods or services are
  provided or dispensed;
(vii)
  Billing for services provided by non-enrolled providers, certain sanctioned
  providers, or excluded persons;
(viii) Billing for services rendered by
  someone else as though the provider performed the services himself or herself;
(ix) Billing for services provided
  by an individual who is required to be licensed or certified and who did not
  meet that requirement when the service was provided;
(x) Billing for services provided outside the
  provider's scope of practice;
(xi)
  Upgrading services billed and rendered from those actually ordered; and
(xii) Upcoding services billed or
  billing a higher level of service than those actually provided;
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 2 - PROVIDER PARTICIPATION › Section 471-2-006 - AUDITS

Current through June 17, 2024
All services for which claims for payment are submitted to the
	 Department are subject to audit. During a review audit, the provider must
	 furnish to the Department, or its authorized representative, pertinent
	 information regarding claims for payment. If an audit reveals that incorrect
	 payments were made or that the provider's records do not support payments that
	 have been made, the provider shall make restitution.
006.01
SAMPLING AND
  EXTRAPOLATION.
The Department's procedure for auditing providers
  may involve the use of sampling and extrapolation. The provider shall pay to
  the Department the entire extrapolated amount of incorrect payments calculated
  under this procedure after notice and opportunity for hearing.
006.02
HEARINGS.
The
  Department must allow the provider an opportunity to rebut the Department's
  audit findings. If the findings are based on sampling and extrapolation, in
  lieu of accepting the Department's sampling and extrapolation, the provider may
  present an audit of 100 percent of the claims filed and services rendered
  during the audit period. This audit must be completed by an independent auditor
  with no affiliation to the provider. Any audit of this type must demonstrate
  that the provider's records for the unaudited services provided during the
  audit period were in compliance with the Department's regulations. The provider
  must be prepared to submit supporting documentation to demonstrate this
  compliance.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 2 - PROVIDER PARTICIPATION › Section 471-2-007 - APPEAL RIGHTS

Current through June 17, 2024
Any adverse action under Title 471 NAC may be appealed to the Medicaid
	 Director by the person or entity against whom the action was taken.
007.01
HEARING REQUEST
  PROCEDURE.
The person or entity appealing an adverse action must
  submit a written hearing request to the Medicaid Director.
007.01(A)
DEADLINES.
The following deadlines apply when submitting an appeal request:
(i) Administrative sanctions must be appealed
  within 30 days of the date of the action;
(ii) Refund requests must be appealed within
  30 days of the date of the action;
(iii) All other actions must be appealed
  within 90 days of the date of the action.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 2 - PROVIDER PARTICIPATION › Section 471-2-008 - DISCLOSURE OF INFORMATION BY PROVIDERS

Current through June 17, 2024
Under 42 CFR 455, Subpart B, the Department requires providers to
	 disclose the following information:
(1) Ownership and control;
(2) Business transactions; and
(3) The providers' owners and other persons
  convicted of crimes against Medicare, Medicaid, or Title XX (Social Services
  Block Grant) programs.
008.01
OWNERSHIP AND CONTROL.
For each managing employee,
  person or entity with an ownership or control interest in the provider, and
  subcontractor of which the provider owns at least five percent, a provider must
  disclose the following:
(1) The name, address
  including, as applicable, the primary business address, every business
  location, and P.O. Box address, date of birth or incorporation, and Tax
  Identification Number or social security number as applicable;
(2) Whether anyone is related to another as
  spouse, parent, child, or sibling; and
(3) The name of any other disclosing entity
  in which a person named in this chapter has an ownership or controlling
  interest.
008.01(A)
PERIODIC SURVEY AND CERTIFICATION.
Any provider that
  is subject to periodic survey and certification of its compliance with Medicaid
  standards must supply this information to the Department at the time it is
  surveyed. Any provider that is not subject to periodic survey and certification
  must supply the information before entering into a service provider agreement
  with the Department as a part of the initial enrollment, re-enrollment,
  reactivation, or revalidation.
008.01(B)
DISCLOSURE OF
  OWNERSHIP.
The Department must not approve a service provider
  agreement, and must terminate an existing service provider agreement, if the
  provider fails to disclose ownership or control information. The Department
  shall not pay a provider who fails to disclose ownership or control
  information.
008.01(C)
CHANGE OF INFORMATION.
A provider must notify the
  Department of any changes or updates to the information supplied under 471 NAC
  2 not later than 35 days after such changes or updates take
  effect.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 3 - PAYMENT FOR MEDICAID SERVICES › Section 471-3-001 - 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 3 - PAYMENT FOR MEDICAID SERVICES › Section 471-3-003 - APPROVAL AND PAYMENT

Current through June 17, 2024
003.01
APPROVAL.
Payment for medical care and services
  through Medicaid funds must be approved by the Department.
003.01(A)
CONDITIONS FOR
  APPROVAL.
Claims will be approved for payment when all of the
  following conditions are met:
(i) The
  provider was enrolled and eligible for payment under the Nebraska Medicaid
  State Plan on the date the service was provided;
(ii) The client was eligible for Medicaid
  when the service was provided, or the service was provided during the period of
  retroactive eligibility;
(iii) No
  more than 6 months have elapsed from the date of service when the claim is
  received by the Department (see 471 NAC 3-002.01A for exceptions);
(iv) The medical care and services are within
  the guidelines of Medicaid;
(v) The
  client's clinical record must contain information to meet state requirements;
  and
(vi) A trading partner
  agreement has been approved, if required, for clearinghouses, billing agents,
  and providers submitting claims using electronic transactions.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 3 - PAYMENT FOR MEDICAID SERVICES › Section 471-3-004 - BILLING REQUIREMENTS

Current through June 17, 2024
004.01
CLAIMS SUBMISSION.
Providers will submit claims for
  payment for medical services on the appropriate Medicaid billing forms as
  identified by the Department or the appropriate health care claim format for
  electronic transactions. Billing requirements for specified services are found
  in the applicable 471 NAC chapter.
004.02
CLAIM
  CERTIFICATION.
The submission of the claim form by the provider,
  the provider's authorized representative, or the provider's billing agent on
  behalf of an approved provider certifies:
(A)
  The services were medically indicated and necessary to the health of the
  patient, and were personally rendered by the provider or under the provider's
  direction;
(B) The services 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;
(C) The amounts claimed are in compliance
  with the Department's policies, and no additional charge has been or will be
  made;
(D) The information on the
  claim is true, accurate, and complete;
(E) Each service is documented in the
  provider's files, and documentation is available to the Department, the United
  States Department of Health and Human Services, and state and federal fraud and
  abuse units; and
(F) The provider
  understands payment and resolution of this claim will be made from federal and
  state funds, and any false claims, statements, or documents, or concealment of
  a material fact may be prosecuted under applicable federal or state
  laws.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 3 - PAYMENT FOR MEDICAID SERVICES › Section 471-3-005 - THIRD PARTY RESOURCES

Current through June 17, 2024
005.01
THIRD PARTY RESOURCE PAYMENT.
All third party
  resources available to a Medicaid client must be utilized for all or part of
  their medical costs before Medicaid. Medicaid payment is made only after all
  third party resources have been exhausted or met their legal contractual or
  legal obligations to pay. Medicaid is the payor of last resort.
005.01(A)
EXCEPTIONS.
The Nebraska Chronic Renal Disease Program
  and the Medically Handicapped Children's Program are not included as a third
  party resource.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 4 - AMBULANCE SERVICES › Section 471-4-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern services provided under the Medical Assistance
	 Act, 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 4 - AMBULANCE SERVICES › Section 471-4-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
ADVANCED LIFE SUPPORT
  (ALS) SERVICES.
An emergency medical service that utilizes
  personnel that have been trained and licensed as advanced emergency medical
  technicians, emergency medical technician-intermediates, or paramedics and has
  equipment available commensurate with that level of training..
002.02
BASIC LIFE SUPPORT (BLS)
  SERVICES.
An emergency medical service that utilizes personnel
  that have been trained and licensed, as a minimum, as emergency medical
  technicians and has equipment available commensurate with that level of
  training.
002.03
EMERGENCY TRANSPORT.
Services provided after the
  sudden onset of a medical condition manifesting itself by acute symptoms of
  sufficient severity, including severe pain that the absence of immediate
  medical attention could reasonably be expected to result in:
(A) Placing the client's health in serious
  jeopardy;
(B) Serious impairment to
  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 4 - AMBULANCE SERVICES › Section 471-4-003 - PROVIDER REQUIREMENTS

Current through June 17, 2024
003.01
GENERAL PROVIDER REQUIREMENTS.
Providers of ambulance
  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 chapter, the individual provider participation
  requirements in this chapter will govern.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 4 - AMBULANCE SERVICES › Section 471-4-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
GENERAL REQUIREMENTS.
004.01(A)
MEDICAL NECESSITY OF
  THE SERVICE.
Medical necessity is established when the client's
  condition is such that use of any other method of transportation is
  contraindicated. In any case in which some means of transportation other than
  an ambulance could be used without endangering the client's health, whether or
  not such other transportation is actually available, Medicaid will not make
  payment for ambulance service. Claims for ambulance services must include
  adequate documentation for determination of medical necessary.
004.01(B)
SERVICES PROVIDED FOR
  CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE.
See 471 NAC
  1.
004.01(C)
HEALTH
  CHECK SERVICES.
See 471 NAC 33.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 4 - AMBULANCE SERVICES › Section 471-4-005 - BILLING AND PAYMENT FOR AMBULANCE 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 Chapter 3. In the
  event that individual billing requirements in 471 NAC 3 conflict with billing
  requirements outlined in this chapter 4, the individual billing requirements in
  this chapter 4 will govern.
005.01(B)
SPECIFIC BILLING
  REQUIREMENTS.
005.01(B)(i)
BILLING INSTRUCTIONS.
The provider must bill Medicaid
  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) and Current
  Procedural Terminology (CPT) procedure codes used by Medicaid are listed in the
  Nebraska Medicaid Practitioner Fee Schedule.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 5 - CHIROPRACTIC SERVICES › Section 471-5-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern services provided under the Medical Assistance
	 Act, 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 5 - CHIROPRACTIC SERVICES › Section 471-5-002 - PROVIDER REQUIREMENTS

Current through June 17, 2024
002.01
GENERAL PROVIDER REQUIREMENTS.
Providers of
  chiropractic 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 chapter, the individual provider participation
  requirements in this chapter will govern.
002.02
SERVICE SPECIFIC PROVIDER
  REQUIREMENTS.
If chiropractic services are provided outside of
  Nebraska, the chiropractor must be licensed in the state in which the services
  are provided.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 5 - CHIROPRACTIC SERVICES › Section 471-5-003 - SERVICE REQUIREMENTS

Current through June 17, 2024
003.01
GENERAL REQUIREMENTS.
003.01(A)
MEDICAL
  NECESSITY.
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.
003.01(B)
SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED
  CARE. See 471 NAC 1.
003.01(C)
HEALTH CHECK SERVICES.
  See 471 NAC 33.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 5 - CHIROPRACTIC SERVICES › Section 471-5-004 - BILLING AND PAYMENT FOR CHIROPRACTIC SERVICES

Current through June 17, 2024
004.01
BILLING.
004.01(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 chapter, the individual billing requirements in
  this chapter will govern.
004.01(B)
SPECIFIC BILLING
  REQUIREMENTS.
004.01(B)(i)
BILLING INSTRUCTIONS.
The provider must bill Medicaid,
  using the appropriate claim form or electronic format.
004.01(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) and Current
  Procedural Terminology (CPT) procedure codes used by Medicaid are listed in the
  Nebraska Medicaid Practitioner Fee Schedule.
004.01(B)(iii)
CHIROPRACTIC
  TREATMENT.
The chiropractor must list the following information on
  the claim when billing Medicaid:
(1) The
  diagnosis which includes the level of subluxation;
(2) The symptom(s) that directly relates to
  the diagnosis of subluxation; and
(3) The initial date of treatment billed to
  Medicaid for the reported diagnosis.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 6 - DENTAL SERVICES › Section 471-6-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern services provided under the Medical
	 Assistance Act, 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 6 - DENTAL SERVICES › Section 471-6-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
ADEQUATE OCCLUSION FOR
  PARTIAL DENTURES.
Adequate occlusion for partial dentures is first
  molar to first molar, or a similar combination of anterior and posterior teeth
  on the upper or lower arch in occlusion.
002.02
DIAGNOSTIC RECORDS.
A medical history, a dental and orthodontic history, clinical
  examination, plaster study models of the teeth, photographs of the patient's
  face and teeth, a panoramic or other x-rays of all the teeth, a facial profile
  x-ray, and other appropriate x-rays.
002.03
HANDICAPPING MALOCCLUSION.
A handicapping malocclusion is an improper alignment of the teeth
  due to one of two conditions:
(A)
  Craniofacial birth defect that is affecting the occlusion; or
(B) Mutilated and severe
  malocclusions.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 6 - DENTAL SERVICES › Section 471-6-003 - PROVIDER REQUIREMENTS

Current through June 17, 2024
003.01
GENERAL PROVIDER REQUIREMENTS.
Providers of dental
  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 chapter, the individual provider participation
  requirements in this chapter will govern.
003.02
PROVIDER SPECIFIC
  REQUIREMENTS.
If services are provided in another state, the
  dentist or dental hygienist must be licensed in that state, must practice
  within his or her scope of practice as defined by the licensing laws for that
  state, and must be enrolled in Medicaid by complying with the provider
  agreement requirements included in this chapter.
003.02(A)
PROVIDER
  AGREEMENT.
Providers of dental services must complete and sign
  Form MC-19, Service Provider Agreement, and submit the completed form to the
  Department for approval to participate in Medicaid.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 6 - DENTAL SERVICES › Section 471-6-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
GENERAL REQUIREMENTS.
004.01(A)
MEDICAL
  NECESSITY.
Medicaid incorporates the definition of medical
  necessity from 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.
  Services may be subject to the specific limitations or prior authorization
  requirements as listed in this chapter.
004.01(A)(i)
DOCUMENTATION OF
  MEDICAL NECESSITY.
Documentation of medical necessity is required
  on all procedures. The documentation should be in the client's dental chart
  which must be available to the Department upon request.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 6 - DENTAL SERVICES › Section 471-6-005 - BILLING AND PAYMENT FOR DENTAL 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 this chapter, the billing requirements in this chapter will
  govern.
005.01(B)
SPECIFIC BILLING REQUIREMENTS.
005.01(B)(i)
BILLING
  INSTRUCTIONS.
The provider must bill Medicaid using the procedure
  codes outlined in the Nebraska Medicaid Dental Fee Schedule and in accordance
  with the billing instructions. The fees listed on the dental claim must be the
  dentist's usual and customary charge for each procedure code.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 6 - DENTAL SERVICES › Section 471-6-006 - TELEDENTISTRY

Current through June 17, 2024
006.01
GENERAL REQUIREMENTS.
Teledentistry follows the requirements of telehealth in
  accordance with 471 NAC 1. Services requiring hands on professional care are
  excluded.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 7 - DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND MEDICAL SUPPLIES (DMEPOS) › Section 471-7-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern services provided under the Medical Assistance
	 Act, 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 7 - DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND MEDICAL SUPPLIES (DMEPOS) › Section 471-7-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply.
002.01
APPARENT LIFE-THREATENING
  EVENT (ALTE).
Apparent life threatening events (ALTE) are episodes
  that are frightening to the observer and characterized by some combination of
  central or obstructive apnea, color change, marked change in muscle tone,
  choking, or gagging.
002.02
AUGMENTATIVE COMMUNICATION DEVICES.
Augmentative
  communication devices are any modes of communication other than
  speech.
002.03
AUTHORIZED DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND
  MEDICAL SUPPLIES (DMEPOS) PROVIDER.
Providers authorized to
  prescribe durable medical equipment, prosthetics, orthotics, and medical
  supplies (DMEPOS) include physicians, nurse practitioners, clinical nurse
  specialists, or physician assistants.
002.04
BED-CONFINED.
The client's condition is such that the client is confined to bed, although not
  necessarily all of the time.
002.05
CUSTOM FABRICATED.
Made for a specific client from his
  or her individualized measurements.
002.06
CUSTOM
  FITTED.
Substantial adjustments are made to a prefabricated item
  by a specially trained professional to meet the needs and unique shape of an
  individual client.
002.07
DURABLE MEDICAL EQUIPMENT.
Equipment which:
(A) Withstands repeated use;
(B) Is primarily and customarily used to
  serve a medical purpose;
(C) Is not
  useful to a person in the absence of an illness or injury; and
(D) Is appropriate for use in the client's
  home.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 7 - DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND MEDICAL SUPPLIES (DMEPOS) › Section 471-7-003 - PROVIDER REQUIREMENTS

Current through June 17, 2024
003.01
GENERAL PROVIDER REQUIREMENTS.
Providers of durable
  medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) 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 chapter, the individual
  provider participation requirements in this chapter will govern.
003.02
SERVICE SPECIFIC PROVIDER
  REQUIREMENTS.
To participate in Medicaid, providers must be
  enrolled as a rental and retail supplier with the appropriate primary specialty
  type as outlined on the Form MC-19, Service Provider Agreement. Providers must
  meet any applicable state and federal laws governing the provision of their
  services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 7 - DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND MEDICAL SUPPLIES (DMEPOS) › Section 471-7-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
GENERAL SERVICE REQUIREMENTS.
Medicaid covers
  medically necessary durable medical equipment, prosthetics, orthotics, and
  medical supplies (DMEPOS) when prescribed by an authorized durable medical
  equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider.
004.01(A)
MEDICAL
  NECESSITY.
The provider must obtain written documentation from the
  prescribing authorized durable medical equipment, prosthetics, orthotics, and
  medical supplies (DMEPOS) provider which justifies the medical necessity for
  durable medical equipment, prosthetics, orthotics, and medical supplies
  (DMEPOS). The original documentation of medical necessity must be kept on file
  by the provider. In addition to meeting the requirements outlined in 471 NAC 1
  the documentation must:
(1) Be signed by the
  authorized durable medical equipment, prosthetics, orthotics, and medical
  supplies (DMEPOS) provider's own hand and dated, using the date the
  documentation is signed;
(2)
  Specify the start date of the order;
(3) Include the authorized durable medical
  equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider's
  name, address, and telephone number;
(4) Include the diagnosis and an estimate of
  the total length of time the item will be needed;
(5) Be sufficiently detailed, including all
  options or additional features which will be separately billed or will require
  an upgraded procedure code;
(6)
  Describe the ordered item(s) using either a narrative description or a brand
  name and model number, including all options or additional features;
(7) For supplies, include appropriate
  information on the quantity used, frequency of change, and duration of need;
  and
(8) Include information
  substantiating that all Medicaid coverage criteria for the item(s) are
  met.
004.01(A)(i)
MEDICAID CERTIFICATION OF MEDICAL NECESSITY FORMS.
Use
  of the following Medicaid Certification of Medical Necessity (CMN) forms are
  required:
(1) Form MS-78, Augmentative
  Communication Device Selection Report;
(2) Form MS-79, Wheelchair and Wheelchair
  Seating System Selection Report; or
(3) Form MS-80, Air Fluidized and Low Air
  Loss Bed Certification of Medical Necessity.
004.01(A)(ii)
MEDICARE
  CERTIFICATION OF MEDICAL NECESSITY FORMS.
Use of the following
  Medicare Certification of Medical Necessity (CMN) form is required: Medicare
  Attending Physician's Certificate of Medical Necessity for Home Oxygen
  form.
004.01(A)(iii)
RECERTIFICATION OF MEDICAL NECESSITY.
Documentation of
  medical necessity must be updated annually or when the authorized durable
  medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS)
  provider's estimated quantity, frequency, or duration of the client's need has
  expired, whichever occurs first.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 8 - HEARING AIDS › Section 471-8-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern services provided under the Medical
	 Assistance Act, 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 8 - HEARING AIDS › Section 471-8-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
ASSISTIVE LISTENING
  DEVICE.
Any instrument or device that helps overcome hearing
  loss.
002.02
BEHIND THE
  EAR (BTE).
All parts of the hearing aid are behind the ear (BTE)
  except for the ear piece that is connected by tubing to the behind the ear
  (BTE) parts.
002.03
COMPLETELY IN THE CANAL (CIC).
The hearing aid is
  completely in the ear (ITE) canal.
002.04
HEARING AID.
Any wearable instrument or device, including any parts, attachments, or
  accessories, but excluding batteries or cords, that is designed for or offered
  for the purpose of aiding or compensating for impaired human hearing and that
  is programmed to a specific individual's hearing loss. Over-the-counter
  amplification devices with generic settings are excluded.
002.05
IN THE CANAL
  (ITC).
The hearing aid is mostly in the ear (ITE) canal.
002.06
IN THE EAR
  (ITE).
The entire hearing aid fits in the area just outside of the
  ear canal known as the concha bowl.
002.07
OTOLARYNGOLOGY
  SPECIALIST.
A physician who specializes with disorders and
  conditions of the ear, nose, and throat region and related areas of the head
  and neck.
002.08
RECEIVER IN THE CANAL (RIC).
Hearing aid with most
  parts behind the ear (BTE) except the receiver that is in the ear (ITE) and
  connected by a wire to the behind the ear (BTE) parts.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 8 - HEARING AIDS › Section 471-8-003 - PROVIDER REQUIREMENTS

Current through June 17, 2024
003.01
GENERAL PROVIDER REQUIREMENTS.
Providers of hearing
  aids 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 chapter, the individual provider participation
  requirements in this chapter will govern.
003.02
STANDARDS OF
  PARTICIPATION.
To participate in Medicaid, hearing aid dispensers
  must complete and sign Form MC-19, Service Provider Agreement, and submit the
  completed form to the Department for approval. Hearing aid dispensers must be
  licensed by the Department as a:
(1) Hearing
  instrument specialist and audiologist;
(2) Audiologist; or
(3) Hearing instrument specialist.
003.02(A)
OUT OF STATE
  PROVIDERS.
If the services are provided outside Nebraska, the
  dispenser must be:
(i) Licensed by the
  appropriate agency of the state in which they practice; and
(ii) Enrolled with Medicaid as a hearing aid
  service provider.
003.02(B)
HEARING AID
  BATTERIES.
Pharmacies and durable medical equipment, prosthetics,
  orthotics, and supplies (DMEPOS) providers may dispense hearing aid batteries
  if enrolled as a Medicaid provider.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 8 - HEARING AIDS › Section 471-8-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
GENERAL REQUIREMENTS.
004.01(A)
MEDICAL
  NECESSITY.
Medicaid incorporates the definition of medical
  necessity from 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)
PRIOR AUTHORIZATION.
Medicaid requires prior
  authorization for certain items and services, as outlined on the Nebraska
  Medicaid Hearing Aid Fee Schedule.
004.01(B)(i)
PRIOR AUTHORIZATION
  PROCEDURE FOR HEARING AIDS, ASSISTIVE LISTENING DEVICES, AND
  ACCESSORIES.
Medicaid requires that the following information be
  submitted when requesting prior authorization for all hearing aids and
  assistive listening devices billed at $
  500.01 or greater per unit, and
  accessories of $150 or greater per line item:
(a) A complete audiogram;
(b) The name of the examiner or dispenser
  performing the audiogram;
(c) The
  type of hearing aid or assistive listening device being recommended and any
  accessories;
(d) The estimated cost
  of the hearing aid or assistive listening device;
(e) The estimated cost of each item being
  provided;
(f) The hearing aid
  dispenser's provider number; and
(g) The hearing aid dispenser's name, address
  and phone number.
004.01(B)(i)(1)
PRIOR
  AUTHORIZATION FORM.
Form DM-5H, Physician's Report on Hearing
  Loss, must be used when submitting a request for prior authorization. All
  requests for prior authorization, and supporting documentation, must be
  submitted to the Department or the utilization management organization under
  contract with the Department.
004.01(B)(ii)
PRIOR AUTHORIZATOIN
  PROCEDURE FOR REPAIRS.
All requests for prior authorization, and
  supporting documentation, must be submitted to the Department or the
  utilization management organization under contract with the Department.
  Medicaid requires that the following information be submitted when requesting
  prior authorization for all repairs of $150 or greater per line item:
(1) The estimated cost of the
  repair;
(2) The estimated cost of
  each item being provided;
(3) The
  hearing aid dispenser's provider number; and
(4) The hearing aid dispenser's name, address
  and phone number.
004.01(C)
EAR, NOSE, AND THROAT
  (ENT) EVALUATIONS.
Medicaid requires that a client be evaluated by
  a licensed otolaryngology specialist who is an approved Medicaid provider when
  the following criteria is met:
(i) The client
  has a conductive hearing loss;
(ii)
  The client has a unilateral hearing loss;
(iii) The client has asymmetric hearing
  loss;
(iv) The client reports
  dizziness; or
(v) The client is age
  16 or younger.
004.01(D)
SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED
  CARE. See 471 NAC 1.
004.01(E)
HEALTH CHECK SERVICES.
  See 471 NAC 33
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 8 - HEARING AIDS › Section 471-8-005 - BILLING AND PAYMENT FOR HEARING AIDS

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 chapter, the individual billing requirements in
  this chapter will govern.
005.01(B)
SPECIFIC BILLING REQUIREMENTS.
Providers must submit
  claims to the Department on the appropriate claim form or electronic format.
  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.
005.01(B)(i)
PROCEDURE
  CODES.
Healthcare Common Procedure Coding System (HCPCS) and
  Current Procedural Terminology (CPT) procedure codes used by Medicaid are
  listed in the Nebraska Medicaid Practitioner Fee Schedule.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 9 - HOME HEALTH AGENCIES AND SKILLED NURSING SERVICES › Section 471-9-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern services provided under the Medical Assistance
	 Act, 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 9 - HOME HEALTH AGENCIES AND SKILLED NURSING SERVICES › Section 471-9-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
ADVANCED
  DIRECTIVE.
A legal document, including, but not limited to, a
  living will, signed by a competent person, to provide guidance for medical and
  health-care decisions in the event the client becomes incapable to make such
  decisions.
002.02
HOME
  HEALTH AGENCY.
A person or any legal entity which provides skilled
  nursing or minimum of one other therapeutic service as defined by the
  Department on a full-time, part-time, or intermittent basis to person in a
  place of temporary or permanent residence used as a the person's
  home.
002.03
HOME
  HEALTH SERVICES.
Services provided to a client in the client's
  place of residence. The residence does not include a hospital, skilled nursing
  facility, or nursing facility. A nurse practitioner, physician assistant, or
  clinical nurse specialist are able to order home health services.
002.04
SKILLED NURSING
  SERVICE.
Skilled nursing services are those services provided by a
  private duty nurse (PDN) or a nurse employed by a home health agency in a
  client's home or current living arrangement. Skilled nursing services do not
  include services provided in a hospital, skilled nursing facility, or nursing
  facility.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 9 - HOME HEALTH AGENCIES AND SKILLED NURSING SERVICES › Section 471-9-003 - PROVIDER REQUIREMENTS

Current through June 17, 2024
003.01
GENERAL PROVIDER REQUIREMENTS.
Providers of home
  health services must comply with all applicable provider participation
  requirements codified in 471 Nebraska Administrative Code (NAC) 2 and 3. In the
  event that participation requirements in 471 NAC 2 or 3 conflict with
  requirements outlined in this chapter, the participation requirements in this
  chapter will govern.
003.02
SPECIFIC PROVIDER REQUIREMENTS.
003.02(A)
PLAN OF CARE AND
  TREATMENT RECORD.
The home health agency must maintain a clinical
  record that includes the plan of care signed by the attending physician, nurse
  practitioner, physician assistant, or clinical nurse specialist responsible for
  the client's care. The attending physician, nurse practitioner, physician
  assistant, or clinical nurse specialist and home health agency personnel must
  review the total plan of care and treatment record at least every 60 days. The
  home health agency must maintain these records on all Medicaid clients and make
  them readily available upon the Department's request.
003.02(B)
COST
  REPORTS.
The home health agency must provide a cost report upon a
  request made by the Department.
003.02(C)
LICENSING.
Providers of nursing services must be licensed by the Department of Health and
  Human Services Division of Public Health or by the appropriate licensing agency
  of the state in which they practice, as an individual registered nurse (RN) or
  licensed practical nurse (LPN).
003.02(D)
PROVIDER
  DOCUMENTATION.
The nurse must maintain records to document
  services provided and the time worked for which payment is claimed. These
  records must be available to the Department upon request. Records must be
  retained for no fewer than six years for audit purposes. Records must include:
(i) Current, signed physician, nurse
  practitioner, physician assistant, or clinical nurse specialist orders for the
  care provided;
(ii) Assessment of
  the client's health status;
(iii)
  Plan of care;
(iv) Nurse's notes
  documenting the care provided; and
(v) Time sheets documenting the date and
  times that care was provided.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 9 - HOME HEALTH AGENCIES AND SKILLED NURSING SERVICES › Section 471-9-004 - SERVICES 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.
  Durable medical equipment, prosthetics, orthotics, and medical supplies
  (DMEPOS) must meet the guidelines outlined in 471 NAC 7. In addition to the
  medical necessity criteria outlined in 471 NAC 1, all home health services and
  skilled nursing services must be:
(i)
  Necessary to a continuing medical treatment plan;
(ii) Prescribed by a licensed physician,
  nurse practitioner, physician assistant, or clinical nurse specialist;
  and
(iii) Recertified by the
  licensed physician, nurse practitioner, physician assistant, or clinical nurse
  specialist at least every 60 days.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 9 - HOME HEALTH AGENCIES AND SKILLED NURSING SERVICES › Section 471-9-005 - BILLING AND PAYMENT FOR HOME HEALTH AGENCIES

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 2 and 471 NAC 3.
  In the event the individual billing requirements in 471 NAC 2 and 471 NAC 3
  conflict with billing requirements outlined in this chapter, the individual
  billing requirements in this chapter will govern.
005.01(B)
SPECIFIC BILLING
  REQUIREMENTS.
005.01(B)(i)
BILLING INSTRUCTIONS.
The provider must bill Medicaid,
  using the appropriate claim form or electronic format, in accordance with the
  billing instructions. The signed plan of care must be submitted with the claim.
  Healthcare Common Procedure Coding System (HCPCS) and Current Procedural
  Terminology (CPT) procedure codes used by Medicaid are listed in the Nebraska
  Medicaid Practitioner Fee Schedule. Durable medical equipment and medical
  supplies are billed under the home health agency provider number.
005.01(B)(ii)
PRIVATE DUTY
  NURSING.
Registered nurse (RN) and licensed practical nurse (LPN)
  providers must submit electronically using the standard Health Care Claim
  Professional transaction (ASC X12N 837) or use Form MC-82-N: Private Duty Nurse
  Claim Form. The signed plan of care must be submitted with the claim.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 10 - HOSPITAL SERVICES › Section 471-10-001 - 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 10 - HOSPITAL SERVICES › Section 471-10-005 - NON-COVERED SERVICES

Current through June 17, 2024
The following services are not intended to be an all-inclusive, or
	 exhaustive, list of non-covered services.
005.01
SURGICAL
  PROCEDURES.
The Department does not cover:
(A) Acupuncture;
(B) Angiocardiography, single plane,
  supervision and interpretation in conjunction with cineradiography or
  multi-plane, supervision and interpretation in conjunction with
  cineradiography;
(C)
  Angiocardiography, utilizing CO2 method, supervision and
  interpretation only;
(D)
  Angiography, coronary, unilateral selective injection supervision and
  interpretation only, single view unless emergency;
(E) Angiography, extremity, unilateral,
  supervision and interpretation only, single view unless emergency;
(F) Artificial Heart Transplant;
(G) Ballistocardiogram;
(H) Basal metabolic rate (BMR);
(I) Bronchoscopy, with injection of contrast
  medium for bronchography or with injection of radioactive substance;
(J) Circumcision, female;
(K) Excision of carotid body tumor, with or
  without excision of carotid artery, when used as a treatment for
  asthma;
(L) Extra-intra cranial
  arterial bypass for stroke;
(M)
  Fabric wrapping of abdominal aneurysm;
(N) Fascia lata by incision and area
  exposure, with removal of sheet, when used as treatment for lower back
  pain;
(O) Fascia lata by stripper
  when used as a treatment for lower back pain;
(P) Hypogastric or presacral neurectomy
  (independent procedure);
(Q)
  Hysterotomy, non-obstetrical, vaginal;
(R) Icterus index;
(S) Ileal bypass or any other intestinal
  surgery for the treatment of obesity;
(T) Kidney decapsulation, unilateral and
  bilateral;
(U) Ligation of femoral
  vein, unilateral and bilateral, when used as treatment for post-phlebotic
  syndrome;
(V) Ligation of internal
  mammary arteries, unilateral or bilateral;
(W) Ligation of thyroid arteries (independent
  procedure);
(X) Nephropexy:
  fixation or suspension of kidney (independent procedure), unilateral;
(Y) Omentopexy for establishing collateral
  circulation in portal obstruction;
(Z) Perirenal insufflation;
(AA) Phonocardiogram with interpretation and
  report, and with indirect carotid artery tracings or similar study;
(BB) Protein bound iodine (PBI);
(CC) Radical hemorrhoidectomy, whitehead
  type, including removal of entire pile bearing area;
(DD) Refractive keratoplasty including
  keratomileusis, keratophakia, and radial keratotomy;
(EE) Reversal of tubal ligation or
  vasectomy;
(FF) Sex change
  procedures;
(GG) Splanchicectomy,
  unilateral or bilateral, when used as a treatment for hypertension;
(HH) Supracervical hysterectomy: subtotal
  hysterectomy, with or without tubes or ovaries, one or both;
(II) Sympathectomy, thoracolumbar or lumbar,
  unilateral or bilateral, when used as a treatment for hypertension;
  and
(JJ) Uterine suspension, with
  or without presacral sympathectomy.