reglab/statecodes huggingface dataset:
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 25 - SCHOOL BASED SERVICES › Section 471-25-006 - REIMBURSEMENT METHODOLOGY FOR SCHOOL-BASED SERVICES: DIRECT AND INDIRECT SERVICES

Current through June 17, 2024
006.01
ADHERENCE TO NEBRASKA EDUCATION-BASED MEDICAID ADMINISTRATION
  (NEBMAC) GUIDE.
All claims submitted by a provider must be based
  on random moment time studies which comply with the requirements of the
  Nebraska Education-Based Medicaid Administrative Claiming (NEBMAC) Guide, dated
  September 1, 2017, which is adopted and incorporated herein by this reference.
  A copy of the Nebraska Education-Based Medicaid Administrative Claiming Guide
  is available on the Department's website or by request at 301 Centennial Mall
  South, P.O. Box 95026, Lincoln, NE 68509-5026.
006.02
RETENTION OF
  RECORDS.
Each public school district or Educational Service Unit
  (ESU) and approved cooperative participating in Medicaid administrative
  claiming must separately retain time-study methodology, instructions, financial
  accounting records, and other documents or records related to participation for
  a minimum of six years.
006.03
TIMELY FILING REQUIREMENTS.
School districts,
  Educational Service Units (ESU's) and approved cooperatives must file their
  claims no later than 15 months from the end of the quarter in which direct
  services or indirect services were provided.
006.04
PAYMENT METHODOLOGY.
Expenditures for direct school-based health services that are
  within the scope of Medicaid coverage and furnished to Medicaid eligible
  children may be claimed as medical assistance. Expenditures for administrative
  activities in support of these school-based services including outreach and
  coordination may be claimed as costs of administering Medicaid.
006.04(A)
DIRECT SERVICE
  QUARTERLY INTERIM SETTLEMENTS.
Quarterly interim settlements for
  services will be based on the quarterly random moment time study (RMTS) and use
  of the interim cost reports compiled on a quarterly basis. The cost report then
  calculates the amount of reimbursement that each school district is eligible to
  receive as an interim payment.
006.04(A)(i)
ANNUAL SETTLEMENT.
On an annual basis, a cost
  settlement process must be completed by each school district. Each school
  district completes an annual cost report which compares their total
  Medicaid-allowable costs from the year to each school district's Medicaid
  interim payments delivered during the quarterly reporting periods, to determine
  the final cost reconciliation and settlement. If a provider's interim payments
  exceed the actual, certified costs for Medicaid services provided in schools to
  Medicaid clients, the provider must remit the federal share of the overpayment
  at the time the annual settlement cost report is submitted.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 26 - AMBULATORY SURGICAL CENTER (ASC) SERVICES › Section 471-26-001 - Standards for Participation

Current through June 17, 2024
NMAP covers facility services provided by ambulatory surgical centers
	 in connection with certain surgical procedures. To participate in the Nebraska
	 Medical Assistance Program, an ambulatory surgical center must:
1. Be certified as meeting the requirements
  for an ASC under Medicare;
2. Have
  an agreement with CMS under Medicare to participate as an ASC; and
3. Have an agreement with the Nebraska
  Department of Health and Human Services to participate in NMAP. NMAP covers ASC
  facility services for only the surgical procedures defined in 471 NAC
  26-004. The ASC must accept the
  Department's payment for the facility services as payment in full for those
  services defined as ASC facility services in 471 NAC
  26-002.
001.01 Definition of an ASC
An ASC is a distinct entity that operates exclusively to provide
	 outpatient surgical services to patients. An ASC may be either:
1. Independent (not part of a provider of
  services or any other facility); or
2. Operated by a hospital (under the common
  ownership, licensure, or control of a hospital).
26-001.01A
ASC's Operated by
  Hospitals
: If an ASC is operated by a hospital, it may be covered
  under Medicare as an independent ASC or as a hospital-affiliated ambulatory
  surgical center (HAASC). The Department enrolls ASC's to participate in NMAP as
  they are enrolled to participate in Medicare. To be covered as a
  Medicare-participating ASC operated by a hospital, a facility must:
1. Elect to do so, and continued to be
  covered as an ASC unless CMS determines there is good cause to do
  otherwise;
2. Be a separately
  identifiable entity, physically, administratively, and financially independent
  and distinct from other operations of the hospital; and
3. Meet all Medicare's requirements for
  independent ASC's.
Facilities operated by a hospital as Medicare-participating ASC's are
	 paid according to 471 NAC
	 26-005. Other HAASC's are paid
	 according to 471 NAC 10-010.06.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 26 - AMBULATORY SURGICAL CENTER (ASC) SERVICES › Section 471-26-002 - Covered ASC Procedures

Current through June 17, 2024
NMAP covers ASC facility services performed in connection with
	 procedures on the list of covered ASC procedures in 471-000-409, state defined
	 ASC Services code(s). These procedures are organized in several groups that
	 refer to the facility payment amount available for each group. The ASC receives
	 the same payment for each procedure within a particular group.
The list of covered ASC procedures indicates which procedures may be
	 covered if performed in an ASC; NMAP does not require that these procedures
	 must be performed in an ASC. The general rules regarding the medical necessity
	 of a specific procedure for a specific client apply to ASC services as they do
	 to all other services covered by NMAP.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 26 - AMBULATORY SURGICAL CENTER (ASC) SERVICES › Section 471-26-003 - Covered ASC Facility Services

Current through June 17, 2024
ASC facility services are items and services provided by an ASC in
	 connection with a covered surgical procedure defined in 471 NAC
	 26-002. These items and services are
	 those that would otherwise be covered by NMAP if provided on a inpatient or
	 outpatient basis in a hospital in connection with that surgical
	 procedure.
The fee for ASC facility services includes payment for:
1. Nursing, technician, and related
  services;
2. Use of ASC
  facilities;
3. Drugs, biologicals,
  surgical dressings, splints, casts, and appliances and equipment directly
  related to the provision of a surgical procedure;
4. Diagnostic or therapeutic services or
  items directly related to the provision of a surgical procedure;
5. Administrative, record keeping, and
  housekeeping items and services;
6.
  Blood, blood plasma, platelets, etc.; and
7. Materials for anesthesia.
The fee for ASC facility services does not include payment for medical
	 and other health services, such as physicians' services and prosthetic devices
	 for which payment may be made under other NMAP payment plans, except for
	 intraocular lenses. See 471 NAC
	 26-004, ASC Services Not Included in
	 the ASC Facility Services Fee.
003.01 Nursing, Technician, and Related
  Services
The fee for ASC facility services includes payment for all services
	 provided by nurses and technical personnel who are employees of the ASC in
	 connection with covered procedures. In addition to nursing staff, this includes
	 orderlies, technical personnel, and others involved in patient
	 care.
003.02 Use of ASC
  Facilities
The fee for ASC facility services includes payment for operating and
	 recovery rooms, patient preoperation areas, waiting rooms, and other areas used
	 by the patient or offered for use by the patient's relatives in connection with
	 covered procedures.
003.03
  Drugs, Biologicals, Surgical Dressings, Supplies, Splints, Casts, Appliances,
  and Equipment
The fee for ASC facility services includes payment for all supplies
	 and equipment commonly provided by the ASC in connection with covered
	 procedures. Coverage of drugs and biologicals is limited to those which cannot
	 be self-administered.
The following supplies and dressings are included in the ASC facility
	 services fee:
1. Primary surgical
  dressings that are usually applied first by a physician in the ASC setting.
  These surgical dressings are therapeutic and protective coverings applied to
  lesions on the skin or openings to the skin required as a result of surgical
  procedures; and
2. Splints, casts,
  and other supplies, such as supplies required for the patient and ASC staff,
  that is, gowns, masks, drapes, hoses, scalpels, etc., whether disposable or
  reusable.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 26 - AMBULATORY SURGICAL CENTER (ASC) SERVICES › Section 471-26-004 - ASC Services Not Included in the ASC Facility Services Fee

Current through June 17, 2024
NMAP makes a single payment (the fee for ASC facility services) to an
	 ASC which covers "facility services" provided by the ASC in connection with a
	 covered procedure. The ASC may provide a number of items and services covered
	 by NMAP which are not included in the fee for ASC facility services. The ASC
	 may be part of a medical complex that includes other entities, such as an
	 independent laboratory, a supplier of durable medical equipment, ambulance
	 services, or a physician's office, which NMAP covers separately. Items or
	 services which are not included in the fee for ASC facility services
	 are:
1. Physicians'
  services;
2. The sale or rental of
  durable medical equipment for use in the patient's home;
3. Prosthetic devices, that is, artificial
  legs, arms, and eyes;
4. Ambulance
  services;
5. Orthotic devices, that
  is, leg, arm, back, and neck braces; and
6. Services provided by an independent
  laboratory. The ASC may provide these services and bill NMAP for them in
  addition to the fee for ASC facility serivces. Refer to the appropriate chapter
  in Title 471 for coverage conditions and payment policies.
004.01 Physicians' Services
This category includes most covered services provided in ASC's which
	 are not considered ASC facility services. Physicians' services include services
	 of anesthesiologists administering or supervising the administration of
	 anesthesia to ASC patients and the patient's recovery from the anesthesia.
	 Physicians' services also include any routine pre- and post-operative services,
	 such as office visits, consultations, diagnostic tests, removal of stitches,
	 and changing of dressings. See 471 NAC 18-004.17, Surgery, and 471 NAC
	 18-006, Payment for Physicians'
	 Services.
004.02 Durable
  Medical Equipment
The following items are not included in the fee for ASC facility
	 services; when provided by the ASC facility in connection with a covered
	 procedure, the ASC may bill for these services in addition to the ASC facility
	 services fee:
1. Ace bandages, elastic
  stockings and support hose, Spence boots and other foot coverings, leotards,
  knee supports, surgical leggings, gauntlets, and pressure garments for the arms
  and hands, and which are generally used as secondary coverings;
2. Surgical dressings that are reapplied
  later by others, including the patient or a family member;
3. Recasting and resplinting, when provided
  on a date other than the date the surgical procedure was performed.
When these dressings and supplies are obtained by the patient on a
	 physician's order from a supplier other than the ASC facility, they are covered
	 under 471 NAC 7-000 ff.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 26 - AMBULATORY SURGICAL CENTER (ASC) SERVICES › Section 471-26-005 - Payment for ASC Services

Current through June 17, 2024
005.01 Fee for ASC Facility Services
For services provided on or after January 1, 2008, NMAP will utilize
	 the 2006 Medicare ambulatory surgical center group rates to reimburse for an
	 ambulatory surgical center service. Reimbursement will be the surgical group
	 rate specific to the procedure as established in 471-000-409.
If one covered ambulatory surgical procedure is provided in a single
	 operative session, NMAP pays 100 percent of the applicable group rate. For
	 example, excision of a benign lesion is a "group 1" procedure; therefore, NMAP
	 would pay 100% of the "group 1" rate.
If more than one covered surgical procedure is provided in a single
	 operative session, NMAP pays 100 percent of the applicable group rate for the
	 procedure with the highest rate. NMAP pays for other covered ambulatory
	 surgical procedures performed in the same operative session at 50 percent of
	 the applicable group rate for each procedure. For example, hammertoe repair is
	 a "group 4" procedure and tenotomy is a "group 1" procedure. Payment for these
	 procedures performed in a single operative session in an ASC would be 100% of
	 the "group 4" rate and 50% of the "group 1" rate.
005.02 Reserved
005.03 Payment for Services Not Included in
  the ASC Facility Services Fee
The fee for facility services does not include payment for physicians'
	 services or other services not directly related to the performance of the
	 surgical procedure. (See 471 NAC
	 26-004.) The ASC may bill for these
	 services in addition to the fee for ASC facility services and will be paid
	 according to the appropriate Medicaid payment plan.
005.04 Payment for State-Defined Services
Medicaid may cover payment for facility services provided in connection
	 with certain state-defined services provided in an ASC. See 471 NAC
	 18-004.17E.
005.05 Non-Payment of Other Provider
  Preventable Conditions (OPPCs)
Effective on or after the effective date of this regulation for
	 facility services rendered by an ambulatory surgical center, payment will be
	 denied for the following OPPCs:
1.
  Wrong surgical or other invasive procedure performed on a patient;
2. Wrong surgical or other invasive procedure
  performed on the wrong body part;
3. Wrong surgical or other invasive procedure
  performed on the wrong patient.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 26 - AMBULATORY SURGICAL CENTER (ASC) SERVICES › Section 471-26-006 - Billing Requirements

Current through June 17, 2024
006.01 Required Forms
When billing Medicaid, the ASC must submit on the appropriate form or
	 electronic format (see Claim Submission Table at 471-000-49).
All claims for ASC services must include the date of surgery and the
	 physician's name and license number.
006.02 Procedure Codes
To claim the ASC facility fee, the ASC must use the appropriate
	 HCPCS/CPT procedure codes as outlined in claim completion instructions (see
	 471-000-52) and see 471-000-409, state defined ASC Services code(s).
The ASC must use HCPCS/CPT procedure codes when billing for
	 practitioner services and laboratory services. Regulations listed in 471 NAC
	 4-000 must be used for ambulance services. Regulations listed in 471 NAC 7-000
	 must be used for durable medical equipment and medical
	 supplies.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 27 - NON EMERGENCY TRANSPORTATION (NET) SERVICES › Section 471-27-001 - 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 27 - NON EMERGENCY TRANSPORTATION (NET) SERVICES › Section 471-27-003 - COVERED SERVICES

Current through June 17, 2024
Medicaid covers the most appropriate non-emergency transportation
	 (NET) services necessary to obtain Nebraska Medicaid reimbursed services when
	 one of the following criteria is met:
(A) Client does not own or does not have
  access to a working licensed vehicle;
(B) Client does not have a current valid
  driver's license;
(C) Client is
  unable to drive due to a documented physical, cognitive, or developmental
  limitation;
(D) Client is unable to
  travel or wait by himself or herself due to a documented physical, cognitive,
  or developmental limitation; or
(E)
  Client is unable to secure free transportation as defined in this chapter.
003.01
NON-EMERGENCY
  TRANSPORATION (NET) SERVICES PROVIDED FOR CLIENTS RESIDING IN NURSING
  FACILITIES OR INTERMEDIATE CARE FACILITY FOR PERSONS WITH DEVELOPMENTAL
  DISABILITIES (ICF/DD'S) WHEN MEDICAID IS THE PRIMARY INSURANCE.
Non-emergency transportation (NET) services for nursing facility or
  intermediate care facility for persons with developmental disability (ICF/DD)
  residents may be covered under this chapter for facility discharge
  transportation to a private residence within boundaries of the state of
  Nebraska.
003.02
EARLY
  AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES.
All transportation services for medically necessary early and periodic
  screening, diagnosis, and treatment (EPSDT) covered services will be provided
  without regard to service limitations defined within this chapter, and with
  prior authorization.
003.03
PROVIDER LOCATION.
Non-emergency transportation (NET)
  services are available to the nearest Nebraska Medicaid coverable services
  within a 20-mile radius of the client's residence, able to meet the client's
  medical needs, and willing to accept the client as a patient, unless otherwise
  exempted or approved by the Department.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 27 - NON EMERGENCY TRANSPORTATION (NET) SERVICES › Section 471-27-004 - NON-COVERED SERVICES

Current through June 17, 2024
The following non-emergency transportation (NET) services are not
	 covered by Nebraska Medicaid:
(A)
  Transportation to obtain services not coverable by Nebraska Medicaid;
(B) Transportation for clients residing in
  nursing facilities or intermediate care facilities for persons with
  developmental disabilities (ICF/DD), except circumstances when for facility
  discharge transportation to a private residence within boundaries of the state
  of Nebraska;
(C) Transportation of
  family members to visit a hospitalized or institutionalized member;
(D) Transportation to a durable medical
  equipment (DME) provider that provides a delivery service that can be accessed
  at no cost to the client, in addition to the delivery of durable medical
  equipment (DME) products in lieu of transporting the client;
(E) Transportation for Medicaid covered
  services provided in the client's home such as personal care, home health,
  etc.;
(F) Transportation to a
  pharmacy that provides a delivery service that can be accessed at no delivery
  cost to the client, with the exception of a new prescription requiring
  immediate use not otherwise reasonably accessible to the client; in addition to
  the delivery of pharmacy products in lieu of transporting the client;
(G) Transportation to a hospital emergency
  room;
(H) Client-provided
  transportation utilizing his or her own personal vehicle;
(I) Wait times;
(J) Services provided by Department staff or
  a legally responsible individual for the client; and
(K) No shows.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 27 - NON EMERGENCY TRANSPORTATION (NET) SERVICES › Section 471-27-005 - AUTHORIZATION PROCEDURES

Current through June 17, 2024
Authorization for non-emergency transportation (NET) services must be
	 requested for a scheduled trip at least three business days in advance, with
	 the exception of an unscheduled trip for urgent medical care as defined in this
	 Chapter. The authorization will be requested through the non-emergency
	 transportation (NET) brokerage contracted by the Heritage Health managed care
	 organization or if fee-for-service (FFS), through the Customer Service Center
	 according to the most appropriate mode of transportation for the service
	 provided to the client.
005.01
MINOR CHILDREN.
A minor child under age 13 may not be
  transported by a nonemergency transportation (NET) provider without adult
  supervision by a legally responsible individual or an adult designated by a
  legally responsible individual.
005.02
ADDITIONAL
  PASSENGERS.
The transportation for one legally responsible adult,
  or an adult designated by a legally responsible adult, may be authorized to
  accompany a minor child under age 19 as an additional passenger. The
  transportation for a personal assistance services provider may be authorized to
  accompany a client as an additional passenger.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 27 - NON EMERGENCY TRANSPORTATION (NET) SERVICES › Section 471-27-006 - PAYMENT FOR SERVICES

Current through June 17, 2024
006.01
CONDITIONS FOR PAYMENT.
The provider may bill Medicaid
  only when:
(A) The transportation is
  furnished by a Medicaid enrolled provider to whom a direct vender payment can
  be made; and
(B) The client is
  actually in the vehicle.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 27 - NON EMERGENCY TRANSPORTATION (NET) SERVICES › Section 471-27-007 - PROVIDER PARTICIPATION

Current through June 17, 2024
To participate in the Nebraska Medicaid Program, providers of
	 non-emergency transportation (NET) services must fully meet all applicable
	 local, state, and federal laws and regulations governing the provision of their
	 services.
007.01
DRIVER
  QUALIFICATIONS.
Providers must ensure drivers:
(A) Be age 19 or older;
(B) Possess a current and valid driver's
  license with no more than three points assessed against his or her Nebraska
  driver's license within the past two years, or meet a comparable standard in
  the state in which he or she is licensed to drive;
(C) Not had his or her driver or chauffeur's
  license revoked within past three years.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 27 - NON EMERGENCY TRANSPORTATION (NET) SERVICES › Section 471-27-008 - BACKGROUND CHECKS

Current through June 17, 2024
Records of screening results must be maintained by these carriers and
	 providers, and must be made available to the Department upon request. The
	 following background check requirements apply:
(A) Individual Providers: If the provider is
  an individual, prior to enrollment and annually, the Department will:
(i) Conduct the Nebraska State Patrol Sex
  Offender Registry screening;
(ii)
  Conduct the Criminal History Check; and
(iii) Notify the provider when and how to
  conduct the Nebraska Adult and Child Abuse and Neglect Central Registry
  screening.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 28 - PRESUMPTIVE ELIGIBILITY › Section 471-28-003 - Presumptive Eligibility for Women with Cancer

Current through June 17, 2024
Under Section 1920B of the Social Security Act,
the
	 Nebraska Medical Assistance Program (NMAP) covers services provided by an
	 enrolled NMAP provider to a woman during a presumptive eligibility period when
	 the woman has been screened by the Every Woman Matters Program and found to
	 have breast or cervical cancer. Presumptive eligibility must be determined by a
	 qualified entity.
Beginning September 1, 2001, women determined presumptively eligible
	 will be eligible for the full scope of services under the State Plan during the
	 presumptive eligibility period. A woman may qualify for presumptive eligibility
	 each time a qualified provider finds her to meet the presumptive eligibility
	 requirements.
003.01 Definition of a
  Qualified Entity
Only a qualified entity is allowed to make the presumptive eligibility
	 determination. A qualified provider must meet the following criteria:
1. Is eligible for payments under the
  Medicaid State Plan and provides items and services covered by the NMAP or is
  eligible for payments as an administrative contractor under the State Medicaid
  plan, and
2. Is determined to be
  capable for making presumptive eligibility determinations and has been
  specifically designated in writing by the Medicaid Division as a qualified
  entity for the purpose of determining presumptive eligibility in accordance
  with the requirements listed and any other limitations issued by the Center for
  Medicare and Medicaid Services (CMS).
The provider must immediately notify the Medicaid Division in writing
	 should they no longer meet the required criteria to be a qualified provider.
	 The provider shall discontinue making presumptive eligibility determinations
	 when the requirements for being a qualified provider are no longer
	 met.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 29 - FEDERALLY-QUALIFIED HEALTH CENTERS (FQHC'S) › Section 471-29-002 - Services Provided for Clients Enrolled in the Nebraska Health Connection (NHC)

Current through June 17, 2024
Certain NMAP clients are required to participate in the Nebraska
	 Medicaid Managed Care Program known as the Nebraska Health Connection (NHC).
	 See 471-000-122 for a listing of the NHC plans.
002.01 Health Maintenance Organization (HMO)
  Plans
The NHC HMO plans are required to provide, at a minimum, coverage of
	 services as described in this Chapter. The prior authorization requirements,
	 payment limitations, and billing instructions outlined in this Chapter do not
	 apply to services provided to clients enrolled in an NHC HMO plan with the
	 following exceptions:
1.
Medical Transplants
: As defined under 471 NAC
  18-004.40, transplants continue to require prior authorization by NMAP and are
  reimbursed on a fee-for-service basis, outside the HMO's capitation
  payment;
2.
Abortions
: As currently defined, abortions continue to
  require prior authorization by NMAP and are included in the capitation fee for
  the HMO; and
3.
Family
  Planning Services
: Family planning services do not require a
  referral from a primary care physician (PCP). As defined in 471 NAC 18-004.26,
  the client must be able to obtain family planning services upon request and
  from a provider of choice who is enrolled in NMAP. Family planning services are
  reimbursed by the HMO, regardless of whether the service is provided by a PCP
  enrolled with the HMO or a family planning provider outside the HMO.
Services provided to clients enrolled in an NHC HMO plan are not billed
	 to NMAP. The provider shall provide services only under arrangement with the
	 HMO.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 29 - FEDERALLY-QUALIFIED HEALTH CENTERS (FQHC'S) › Section 471-29-003 - Payment for Services Provided by FQHCs

Current through June 17, 2024
003.01 Definitions
The following definitions apply in this chapter.
Encounter
means a face-to-face visit between
	 a Medicaid-eligible patient and a physician, physician assistant, nurse
	 practitioner, nurse midwife, specialized nurse practitioner, visiting nurse,
	 clinical psychologist, or clinical social worker during which an FQHC service
	 is rendered. Encounters with more than one health professional and multiple
	 encounters with the same health professional which take place on the same day
	 and at a single location constitute a single visit, except for cases in which
	 the patient, subsequent to the first encounter, suffers an illness or injury
	 requiring additional diagnosis or treatment.
Encounter Rate
means the all-inclusive PPS
	 rate that the Department reimburses the FQHC for an encounter.
Encounter Payments
means PPS rate paid to the
	 FQHC by the Department multiplied by the number of encounters billed.
Medicare Cost Report
means the report filed
	 by each provider with its Medicare intermediary as required in the Medicare
	 Rural Health Clinic and Federal Qualified Health Center Manual.
Prospective Payment System (PPS)
means the
	 payment system where in the reimbursement rate is paid for services
	 provided.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 29 - FEDERALLY-QUALIFIED HEALTH CENTERS (FQHC'S) › Section 471-29-004 - Prospective Payment System

Current through June 17, 2024
004.01 Prospective Payment System Base Rates
The Prospective Payment System base rate will be computed as
	 follows:
1. Combine reasonable costs
  from the FQHC fiscal year 1999 and 2000 cost reports; and
2. Divide the costs by the Total Adjusted
  Visits from the two fiscal year cost reports (Form HCFA- 222-92 Worksheet C,
  Part 1, Line 6; or Form HCFA- 2552-96 Worksheet M-3, Line 6).
Beginning October 1, 2001, the PPS base rate will be updated annually
	 based on the Medicare Economic Index (MEI).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 29 - FEDERALLY-QUALIFIED HEALTH CENTERS (FQHC'S) › Section 471-29-005 - Cost Reports

Current through June 17, 2024
Providers participating in the NMAP as FQHCs must submit an annual
	 cost report to the Department.
The Medicare cost report form CMS- 222-92 can be found in the Provider
	 Reimbursement Manual-Part-2 ( Pub. 15-2 ), Chapter 29 located at
http://www.cms.hhs.gov/manuals/PBM/list.asp
on the CMS website.
Each FQHC must report and supply the Department with necessary
	 documentation, cost reports, and any other documentation when
	 requested.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 29 - FEDERALLY-QUALIFIED HEALTH CENTERS (FQHC'S) › Section 471-29-006 - Billing for FQHC Services

Current through June 17, 2024
FQHCs must bill for their services on Form CMS-1450 (see 471-000-51)
	 or electronically using the standard Health Care Claim: Institutional
	 transaction (ASC X12N 837). FQHCs must use the appropriate HCPCS/CPT procedure
	 codes and revenue codes when billing for services.
FQHCs must bill for HEALTH CHECKS (Early and Periodic Screening,
	 Diagnosis, and Treatment-EPSDT-Exams) on Form CMS-1500 (see 471-000-58) or
	 electronically using the standard Health Care Claim: Professional transaction
	 (ASC X12N 837).
FQHCs must bill all laboratory/radiology services and other non-FQHC
	 services on the form CMS-1500 (see 471-000-58) or electronically using the
	 standard health care claim; Professional transaction (ASC X12N 837) using the
	 non-FQHC number.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 30 - HEALTH INSURANCE PREMIUM PAYMENT PROGRAM › Section 471-30-001 - 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
	 to
	 68-991
	 (the Medical Assistance Act). The Health Insurance Premium Payment (HIPP)
	 Program is authorized under §§1905 and 1906 of the Social Security
	 Act.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 30 - HEALTH INSURANCE PREMIUM PAYMENT PROGRAM › Section 471-30-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
COST
  EFFECTIVENESS.
A determination, made by the Department, that
  payment for coverage under a group health plan or individual market health plan
  will be less than the amount of expenditures under the Nebraska Medicaid State
  Plan that Medicaid would have made to provide comparable coverage for the
  client.
002.02
GROUP
  HEALTH PLAN.
Any plan of, or contributed to by, an employer
  (including a self-insured plan) to provide health care (directly or otherwise)
  to the employer's employees, former employees, or the families of employees or
  former employees. A group health plan must meet S. 5000(b)(1) of the Internal
  Revenue Code of 1986, and includes continuation coverage pursuant to Title XXII
  of the Public Health Services Act, S. 4980B of the Internal Revenue Code of
  1986, or Title VI of the Employee Retirement Income Security Act of
  1974.
002.03
INDIVIDUAL
  MARKET HEALTH PLAN.
Individual market is the market for health
  insurance coverage offered to individuals other than in connection with a group
  health plan. For purposes of the Health Insurance Premium Payment (HIPP)
  Program, individual market policies include health plans that comply with the
  requirements of the Patient Protection and Affordable Care Act of 2010 (ACA)
  and may include policies that do not meet all Affordable Care Act (ACA)
  requirements but are still found to provide comprehensive health coverage as
  determined by the Department.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 30 - HEALTH INSURANCE PREMIUM PAYMENT PROGRAM › Section 471-30-003 - PARTICIPATION IN THE HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM

Current through June 17, 2024
003.01
VOLUNTARY PARTICIPATION IN
  HEALTH INSURANCE PREMIUM PAYMENT (HIPP).
Participation in the
  Health Insurance Premium Payment (HIPP) Program is voluntary. For Medicaid
  eligible clients, enrollment in the Health Insurance Premium Payment (HIPP)
  Program does not change the client's eligibility for benefits through the state
  plan or cost sharing obligations under the state plan.
003.02
PARTICIPATION
  DETERMINATION FOR HEALTH INSURANCE PREMIUMPAYMENT (HIPP).
003.02(A)
REQUIRED
  DOCUMENTATION.
The Department may request any documentation from
  the client that it deems to be necessary to determine whether the client's
  enrollment in an available group health plan or individual market health plan
  is cost effective. Documentation that must be submitted includes, but is not
  limited to:
(i) Signed application for
  enrollment in the Health Insurance Premium Payment (HIPP) Program;
(ii) Summary of covered benefits from the
  group health plan or individual market health plan;
(iii) If applicable, verification of the
  client's ongoing medical diagnosis. Verification must be provided by an
  appropriate physician or entity;
(iv) Completed verification form for employer
  sponsored insurance; and
(v)
  Monthly proof of health insurance premium payments.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 30 - HEALTH INSURANCE PREMIUM PAYMENT PROGRAM › Section 471-30-004 - REIMBURSEMENTS

Current through June 17, 2024
Medicaid covers reimbursement of premiums for Medicaid-eligible
	 enrollees in a cost effective group health plan or individual market health
	 plan. Medicaid also covers payment of all deductibles, coinsurance, and other
	 cost sharing obligations under the group health plan or individual market
	 health plan that are for services covered under the Medicaid State Plan.
Reimbursements will be made directly to the policyholder as a
	 reimbursement for the group health insurance or individual market health
	 insurance premiums. The client or policyholder must submit accompanying
	 documentation within sixty days of the date paid showing the premium payment
	 has been made.
004.01
FAMILY MEMBERS.
If a family member who is not eligible
  for Medicaid must be enrolled in the group health plan or individual market
  health plan to obtain coverage under the group health plan or individual market
  health plan for the Medicaid-eligible client, Medicaid covers payment for the
  group health plan premiums for the family member who is not eligible for
  Medicaid.
004.02
DEDUCTIBLES, COINSURANCE, AND OTHER COST SHARING.
The
  Department will pay deductibles, co-insurance, and cost sharing obligations up
  to the Medicaid allowable amounts directly to the enrolled Medicaid provider.
  The provider must submit a claim to the Department in accordance with claim
  submission and payment guidelines outlined in 471 NAC Chapters 2 and 3, as well
  as any submission and payment guidelines included within each service specific
  NAC Title 471 Chapter directly. Payment will be made directly to the provider
  in an amount up to, but not exceeding, the Medicaid allowable amount less any
  payment made to the provider by the group health plan or individual market
  health plan. The provider must accept Medicaid payment as payment in full, and
  cannot bill the client for the difference between the Medicaid payment and the
  billed amount.
Prior to submitting a claim to the Department for payment, the provider
	 must complete the provider enrollment process outlined in 471 NAC Chapter 2 as
	 well as any enrollment requirements included within each service specific NAC
	 Title 471 Chapter.
004.02(A)
FAMILY MEMBERS.
Medicaid does not cover deductibles,
  coinsurance, and other cost sharing obligations under the group health plan or
  individual market health plan for any family member who is not eligible for
  Medicaid.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 30 - HEALTH INSURANCE PREMIUM PAYMENT PROGRAM › Section 471-30-005 - CLIENTS RIGHT TO APPEAL

Current through June 17, 2024
The Health Insurance Premium Payment (HIPP) Program is intended to
	 serve as a cost saving measure for Medicaid, and does not confer any additional
	 benefits upon the client. Accordingly, the client does not have the right to
	 appeal an adverse decision regarding enrollment or participation in the Health
	 Insurance Premium Payment (HIPP) Program.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 31 - SERVICES IN AN INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) › Section 471-31-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
The regulations govern the services provided under Nebraska's Medicaid
	 program as defined by Neb. Rev. Stat. §§
									68-901
	 to et seq.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 31 - SERVICES IN AN INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) › Section 471-31-005 - BILLING AND PAYMENT FOR INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DP) 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
  individual billing requirements in 471 NAC 3 conflict with billing requirements
  outlined in this chapter, the individual billing requirements in this chapter
  govern.
005.01(B)
SPECIFIC BILLING REQUIREMENTS.
005.01(B)(i)
REPORTING BED
  HOLDING DAYS.
Intermediate care facility for individuals with
  developmental disabilities (ICF/DD) must report bed holding days on the
  appropriate claim. The appropriate bed holding days are reported as outlined in
  claim submission instructions: the "nursing facility days"? are adjusted to the
  actual number of days the client was present in the intermediate care facility
  for individuals with developmental disabilities (ICF/DD) at midnight.
005.01(B)(ii)
BILLING FOR THE
  ANNUAL PHYSICAL EXAMINATION.
If the annual physical examination is
  performed solely to meet the Medicaid requirement, the physician must use the
  appropriate Healthcare Common Procedure Coding System code and submit the claim
  to Medicaid. If the physical examination is performed for diagnosis or
  treatment of a specific symptom, illness, or injury and the individual has
  Medicare or other third party coverage, the physician must submit the claim
  through the usual Medicare or other third party process.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 31 - SERVICES IN AN INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) › Section 471-31-006 - UTILIZATION REVIEW

Current through June 17, 2024
Utilization reviews (UR) of Nebraska Medicaid clients residing in an
	 intermediate care facility for individuals with developmental disabilities
	 (ICF/DD) are conducted by the Medicaid review team to determine if clients
	 continue to meet intermediate care facility for individuals with developmental
	 disabilities (ICF/DD) level of care. The utilization review (UR) also evaluates
	 the effectiveness of services provided to clients by intermediate care
	 facilities for individuals with developmental disabilities (ICF/DD).
	 Utilization reviews (UR) will occur at least every six months. The intermediate
	 care facility for individuals with developmental disabilities (ICF/DD) must
	 retain documentation of the utilization review (UR) in the client's permanent
	 record.
006.01
MEDICAID
  REVIEW TEAM.
006.01(A)
MEDICAID REVIEW TEAM RESPONSIBILITIES.
The Medicaid
  review team will:
(1) With input from
  facility staff as needed, establish a utilization review (UR) schedule for each
  intermediate care facility for individuals with developmental disabilities
  (ICF/DD);
(2) Notify the facility
  of the utilization review (UR) at least 30 days prior to the review;
(3) Provide the facility a listing of the
  clients that are reviewed;
(4)
  Provide direction to the facility regarding forms and records required for the
  review:
(5) Determine whether each
  client is approved for a continued stay for a maximum of six months or does not
  meet criteria for a continued stay. When a continued stay is not approved,
  follow the appropriate procedures: and
(6) Notify the facility of the results of the
  utilization review (UR).
006.01(A)(i)
EXPANSION OF REVIEW
  PROCESS.
The Medicaid review team has the authority to expand the
  review process as needed and may include the review of additional client
  records, and interviews with clients and facility staff. In the event the
  Medicaid review team determines the documentation available for review does not
  provide adequate information to make a determination of whether the
  intermediate care facility for individuals with developmental disabilities
  (ICF/DD) level of care is appropriate, the Medicaid review team may conduct
  onsite observations and interview with the client at the facility, interview
  facility staff, and request additional information from the 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 31 - SERVICES IN AN INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) › Section 471-31-007 - HOSPICE SERVICES

Current through June 17, 2024
007.01
DEFINITION OF HOSPICE.
Hospice or hospice services
  must meet the definition outlined in 471 NAC 36.
007.02
STANDARDS FOR
  PARTICIPATION.
To participate in Medicaid, a hospice must be a
  public agency or private organization, or a subdivision of either, primarily
  engaged in providing care to terminally ill individuals and is certified for
  participation in Medicare as a hospice.
007.02(A)
PROVIDER
  ENROLLMENT.
To complete the provider enrollment process for adult
  clients, the hospice must meet the following conditions:
(i) The hospice must have a signed, written,
  non-resident-specific contract with the intermediate care facility for
  individuals with developmental disabilities (ICF/DD): and
(ii) The hospice must complete and submit a
  Nebraska Medicaid provider agreement in its entirety to Medicaid for each
  contracted 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 32 - CHILDREN'S MENTAL HEALTH AND SUBSTANCE USE TREATMENT SERVICES › Section 471-32-001 - General Requirements

Current through June 17, 2024
001.01 Eligibility
An individual is eligible for mental health and/or substance use
	 treatment services set forth in this chapter when:
1. The individual has a diagnosis of a mental
  health or substance use disorder of sufficient duration and intensity to meet
  diagnostic criteria specified within the current version of the Diagnostic and
  Statistical Manual of the American Psychiatric Association; and
2. The mental health or substance use
  disorder results in functional impairment that substantially interferes with or
  limits the individual's role or functioning within his/her family, school or
  community. Coexisting conditions such as organic brain disorders, developmental
  disabilities, intellectual disability, autism spectrum disorders, or behavioral
  disorders, must be carefully evaluated in order to identify the functional
  impairments resulting from the mental health or substance use disorder
  diagnosis and those resulting from the coexisting condition. In the evaluation
  of coexisting conditions, evidence of the conditions will not automatically
  result in denial of eligibility; and
3. The services meet medical necessity
  criteria.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 32 - CHILDREN'S MENTAL HEALTH AND SUBSTANCE USE TREATMENT SERVICES › Section 471-32-002 - Outpatient Mental Health and Substance Abuse Treatment Services

Current through June 17, 2024
002.01 Covered Outpatient Mental Health and
  Substance Use Disorder Treatment Services
Covered services include:
1.
  Crisis Outpatient;
2. Client
  Assistance Program (managed care benefit only);
3. The Initial Diagnostic
  Interview;
4. Psychological
  Testing;
5. Comprehensive Child and
  Adolescent Assessment (CCAA);
6.
  Comprehensive Child and Adolescent Assessment Addendum;
7. Individual Psychotherapy;
8. Group Psychotherapy;
9. Family Psychotherapy;
10. Parent Child Interaction Therapy
  (PCIT);
11. Child-Parent
  Psychotherapy (CPP);
12. Individual
  Substance Use Disorder Counseling;
13. Group Substance Use Disorder
  Counseling;
14. Family Substance
  Use Disorder Counseling;
15.
  Conferences;
16. Community
  Treatment Aide;
17. Medication
  Management; and
18. Sex Offender
  Risk Assessment.