No. 29869 (Amendment): R414-3A-6. Services

DAR File No.: 29869
Filed: 04/26/2007, 04:06
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This amendment is necessary to clarify Medicaid policy regarding hyperbaric oxygen therapy services.

Summary of the rule or change:

This change specifies that only a level one facility accredited by the Undersea and Hyperbaric Medical Society may provide hyperbaric oxygen therapy.

State statutory or constitutional authorization for this rule:

Sections 26-18-3 and 26-1-5

Anticipated cost or savings to:

the state budget:

There is an estimated annual savings of $22,395 to the General Fund and $52,605 in federal funds that results from the companion filings of Sections R414-2A-7 and R414-3A-6. (DAR NOTE: The proposed amendment to Section R414-2A-7 is under DAR No. 29868 in this issue, May 15, 2007, of the Bulletin.)

local governments:

There is no budget impact that results from the companion filings of Sections R414-2A-7 and R414-3A-6, because local governments do not fund hyperbaric oxygen therapy services.

other persons:

Providers lose an estimated $75,000 in annual revenue, which results from the companion filings of Sections R414-2A-7 and R414-3A-6.

Compliance costs for affected persons:

Five current providers may lose up to $15,000 each in annual revenue, unless they achieve the required accreditation proposed in the companion filings of Sections R414-2A-7 and R414-3A-6.

Comments by the department head on the fiscal impact the rule may have on businesses:

The Department believes that requiring this accreditation of providers is appropriate to assure quality care for Medicaid recipients and that the fiscal impact on business is justified. David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

06/14/2007

This rule may become effective on:

06/22/2007

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-3A. Outpatient Hospital Services.

R414-3A-6. Services.

(1) Services appropriate in the outpatient hospital setting for adequate diagnosis and treatment of a client's illness are limited to less than 24 hours and encompass medically necessary diagnostic, therapeutic, rehabilitative, or palliative medical services and supplies ordered by a physician or other practitioner of the healing arts.

(2) Outpatient hospital services include:

(a) the service of nurses or other personnel necessary to complete the service and provide patient care during the provision of service;

(b) the use of hospital facilities, equipment, and supplies; and

(c) the technical portion of clinical laboratory and radiology services.

(3) Laboratory services are limited to tests identified by the Centers for Medicare and Medicaid Services (CMS) where the individual laboratory is CLIA certified to provide, bill and receive Medicaid payment.

(4) Cosmetic, reconstructive, or plastic surgery is limited to:

(a) correction of a congenital anomaly;

(b) restoration of body form following an injury; or

(c) revision of severe disfiguring and extensive scars resulting from neoplastic surgery.

(5) Abortion procedures are limited to procedures certified as medically necessary, cleared by review of the medical record, approved by division consultants, and determined to meet the requirements of Utah Code 26-18-4 and 42 CFR 441.203.

(6) Sterilization procedures are limited to those that meet the requirements of 42 CFR 441, Subpart F.

(7) Nonphysician psychosocial counseling services are limited to evaluations and may be provided only through a prepaid mental health plan by a licensed clinical psychologist for:

(a) mentally retarded persons;

(b) cases identified through a CHEC/EPSDT screening; or

(c) victims of sexual abuse.

(8) Outpatient individualized observation of a mental health patient to prevent the patient from harming himself or others is not covered.

(9) Sleep studies are available only in a sleep disorder center accredited by the American Academy of Sleep Medicine.

(10) Hyperbaric Oxygen Therapy is limited to service in a hospital facility in which the hyberbaric unit [has been]is accredited [or approved]as a level one facility by the Undersea and Hyperbaric Medical Society.

(11) Lithotripsy is covered by an all-inclusive fixed fee. This payment covers all hospital and ambulatory surgery-related services for lithotripsy on the same kidney for 90 days, including repeat treatments. Lithotripsy for treatment of the other kidney is a separate service.

(12) Reimbursement for services in the emergency department is limited to codes and diagnoses that are medically necessary emergency services as described in the provider manual. The diagnosis reflecting the primary reason for emergency services must be used and must be one of the first five diagnoses listed on the claim form.

(13) Take home supplies and durable medical equipment are not reimbursable.

(14) Prescriptions are not a covered Medicaid service for a client with the designation "Emergency Services Only Program" printed on the Medicaid Identification Card.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [July 25, 2006]2007

Notice of Continuation: November 26, 2002

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-2.3; 26-18-3(2); 26-18-4