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Utah Administrative Code (Current through November 1, 2019) |
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R414. Health, Health Care Financing, Coverage and Reimbursement Policy |
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R414-3A. Outpatient Hospital Services |
| R414-3A-1. Introduction and Authority |
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This rule defines the scope of outpatient hospital services available to Medicaid members for the treatment of disorders other than mental disease. This rule is authorized under Section 26-18-3 and governs the services allowed under 42 CFR 440.20. |
| R414-3A-2. Definitions |
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(1) "Outpatient" is defined in 42 CFR 440.20. (2) "Outpatient hospital" is a facility that: (a) is in, or physically connected to, a hospital licensed by the Department as a general hospital, as defined by Subsection 26-21-2(11), and meets the standards set forth in Rule R432-100 and 42 CFR Part 482; (b) meets participation requirements in the Medicare program; and (c) has a Medicaid provider agreement with the Department. |
| R414-3A-3. Member Eligibility Requirements |
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Outpatient hospital services are available to categorically and medically needy individuals. |
| R414-3A-4. Program Access Requirements |
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(1) An outpatient hospital must: (a) Be licensed or formally-approved as a hospital by an officially designated authority for state-standard setting; (b) Meet participation requirements in Medicare as a hospital; (c) Be a hospital that accepts a Medicaid member for treatment and accepts responsibility to make sure the member receives all medically necessary services from Medicaid providers; and (d) Accept financial responsibility for any services a member receives from a non-Medicaid provider. |
| R414-3A-5. Services |
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(1) Services appropriate in the outpatient hospital setting encompass medically necessary diagnostic, therapeutic, rehabilitative, or palliative medical services and supplies. (2) Outpatient hospital services include: (a) the service of nurses or other personnel necessary to complete the service and provide member 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) Cosmetic or reconstructive procedures are set forth in Section R414-1-29. (4) Coverage of sleep studies requires sleep center accreditation through one of the following nationally recognized accreditation organizations: (a) American Academy of Sleep Medicine (AASM); (b) Accreditation Commission for Health Care (ACHC); or (c) The Joint Commission (TJC). (5) Hyperbaric oxygen therapy is limited to service in a facility in which the hyperbaric unit is accredited by the Undersea and Hyperbaric Medical Society. Hyperbaric oxygen therapy is therapy that places the member in an enclosed pressure chamber for medical treatment. |
| R414-3A-6. Prior Authorization |
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Prior authorization is required on certain medical and surgical procedures in accordance with Section R414-1-14. |
| R414-3A-7. Cost Sharing |
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Each Medicaid member is responsible for a copayment as established in the Utah Medicaid State Plan and incorporated by reference in Rule R414-1. |
| R414-3A-8. Reimbursement for Services |
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Latest version.
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Reimbursement for outpatient hospital services is in accordance with Attachment 4.19-B of the Utah Medicaid State Plan, which is incorporated by reference in Rule R414-1. |
| R414-3A-9. Reimbursement for Services |
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Latest version.
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Reimbursement for outpatient hospital services is in accordance with Attachment 4.19-B of the Utah Medicaid State Plan, which is incorporated by reference in Rule R414-1. |