Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 10 - HOSPITAL SERVICES › Section 471-10-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
GENERAL REQUIREMENTS.
004.01(A)
MEDICAL
  NECESSITY.
Services and supplies that do not meet the definition
  of medical necessity are not covered. The fact that the physician has performed
  or prescribed a procedure or treatment or the fact that it may be the only
  treatment for a particular injury, sickness, or mental illness does not mean
  that it is covered by Nebraska Medicaid. Services and supplies which do not
  meet the definition of medical necessity set out above are not covered.
  Approval by the Food and Drug Administration or similar approval does not
  guarantee coverage by the Department. Licensure or certification of a
  particular provider type does not guarantee Nebraska Medicaid
  coverage.
004.01(B)
PRIOR AUTHORIZATION.
The Department requires that
  physicians request prior authorization from the Department before providing:
(1) Medical transplants;
(2) Abortions;
(3) Cosmetic and reconstructive
  surgery;
(4) Bariatric surgery for
  obesity;
(5) Out-of-State Services.
  Exception: Prior authorization is not required for emergency
  services;
(6) Established
  procedures of questionable current usefulness;
(7) Procedures which tend to be redundant
  when performed in combination with other procedures;
(8) New procedures of unproven
  value;
(9) Certain drug
  products;
(10) Sleep study for a
  child under the age of six years old; and
(11) Ventricular Assist Device.
004.01(B)(i)
PRIOR AUTHORIZATION
  PROCEDURES.
The physician must request prior authorization for
  these services in writing, or by using the standard electronic Health Care
  Services Review.
004.01(B)(i)(1)
REQUEST FOR ADDITIONAL EVALUATIONS.
The Department may
  request, and the provider must submit, additional evaluations when the
  Department determines that the medical history for the request is questionable
  or when there is not sufficient information to support the requirements for
  authorization.
004.01(B)(i)(2)
PRIOR AUTHORIZATION APPROVAL/DENIAL PROCESS.
The prior
  authorization request review and determination must be completed by one or all
  of the following Department representatives:
(a) Medical Director;
(b) Designated Department Program
  Specialists; and
(c) Medicaid
  Medical Consultants or Contractors for certain specialties.
004.01(B)(i)(3)
NOTIFICATION PROCESS.
Upon determination of approval
  or denial, the Department provides a written response to the following, as
  applicable, and depending on the source of the request:
(a) Physician(s) submitting or contributing
  to the request;
(b) Caseworker;
  and
(c) Medical Review Organization
  when appropriate.
004.01(B)(ii)
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 not 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 must be submitted within 14 days of the verbal
  authorization. A written or electronic response from the Department will be
  issued upon completion of the review.
004.01(B)(iii)
BILLING AND
  PAYMENT REQUIREMENTS.
Claims submitted to the Department for
  services requiring prior authorization will not be paid without written or
  electronic approval. 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.