R414-10. Physician Services, R414. Health, Health Care Financing, Coverage and Reimbursement Policy, Utah Administrative Code

Utah Administrative Code (Current through November 1, 2019)

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

R414-10-1. Introduction and Authority

Latest version.

(1) The Physician Services Program provides a scope of physician services to meet the basic medical needs of eligible Medicaid members. It encompasses the art and science of caring for those who are ill through the practice of medicine or osteopathy defined in Title 58, Occupations and Professions.

(2) Physician services are a mandatory Medicaid program authorized by Section 1901 of the Social Security Act, Subsections 1861(q)(r) and 1905(a)(5)(6) of the Social Security Act, and Sections 26-1-5 and 26-18-3.

R414-10-2. Definitions

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In addition to the definitions in Rule R414-1, the following definitions apply to this rule:

(1) "Family planning" means diagnosis, treatment, medications, supplies, devices, and related counseling in family planning methods to prevent or delay pregnancy.

(2) "Global surgical procedures" means preoperative office visits and preparation, the operation itself, local infiltration, topical or regional anesthesia when used, and normal follow-up care.

(3) "Physician services", whether furnished in the office, the recipient's home, a hospital, a skilled nursing facility, or elsewhere, means services performed by a Medicaid provider that meet the following standards:

(a) Services are performed within the scope of the physician's license as defined in Title 58, Occupations and Professions;

(b) Services are performed by a doctor of medicine or osteopathy, a doctor of dental surgery or of dental medicine, a doctor of podiatric medicine, a doctor of optometry, a chiropractor, or;

(4) "Practice as a physician assistant" means:

(a) acting as an agent of the supervising physician, and when under the authority of a substitute supervising physician, acting in accordance with a delegation of services agreement; and

(b) performing professional duties within the conduct of a physician assistant in diagnosing, treating, advising, or prescribing for any human disease, ailment, injury, infirmity, deformity, pain, or other condition.

(5) "Services" means the types of medical assistance specified in Subsection 1905(a) of the Social Security Act and interpreted in 42 CFR 440.

R414-10-3. Member Eligibility Requirements

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Physician services are available to categorically and medically needy eligible individuals.

R414-10-4. Program Access Requirements

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(1) An eligible Medicaid member may obtain physician services from any Utah Medicaid provider.

(2) An individual who does not meet United States residency requirements may only receive emergency services, including emergency labor and delivery, to treat an emergency medical condition, as stated in Section R414-1-7.

(a) Medicaid does not cover prenatal and post-partum services for undocumented immigrants.

R414-10-5. Service Coverage and Limitations

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(1) General Information.

(a) Physician services may be provided only within the parameters of accepted medical practice and are subject to limitations and exclusions established by the Department on the basis of medical necessity, appropriateness, and utilization control considerations.

(b) Cosmetic or reconstructive procedures, see Section R414-1-29.

(d) Program limitations and non-covered services are maintained in the Coverage and Reimbursement Code Lookup and updated by notification through the Medicaid Information Bulletin. Medicaid does not cover the following types of services:

(i) Services rendered during a period in which an individual is ineligible for Medicaid;

(ii) Medically unnecessary or unreasonable services;

(iii) Services that fail to meet existing standards of professional practice;

(iv) Services rendered without required prior authorization;

(v) Services, elective in nature, based on patient request or individual preference rather than medical necessity;

(vi) Services claimed fraudulently;

(vii) Services that represent abuse or overuse;

(viii) Services rejected or disallowed by Medicare when the rejection is based on any of the reasons listed in Section R414-10-5;

(ix) Services for which third-party payers are primarily responsible for coverage, such as Medicare, private health insurance, and liability insurance pursuant to Rule R527-936. Medicaid may make a partial payment up to the Medicaid maximum if a third party does not reach the payment limit;

(x) Related services, supplies, or institutional costs during a post-operative recovery period, if the service or procedure is not covered for any of the reasons specified in Section R414-10-5, or due to policy exclusion; and

(xi) Paternity tests.

(e) Alcoholism or drug dependency in an inpatient setting, see Subsection R414-2A-7(2).

(f) A physician assistant who works under the supervision of physician, or as a staff member of a facility, is not an independent practitioner and cannot bill independently.

(i) Service limitations or exclusions that apply to a physician shall also apply to the physician assistant.

(ii) Only a licensed physician may perform the specialty medical services of an assistant surgeon that include complex surgical procedures, while a physician assistant may neither perform specialty medical services nor assist in a surgical procedure.

(iii) Medicaid, as it considers necessary, may apply exceptions to the duties of a supervised-physician assistant in rural areas or in federally-designated health professional shortage areas.

(2) Family Planning Services.

(a) Medicaid does not cover the following family planning services:

(i) Surgical procedures for the reversal of previous elective sterilization on both males and females;

(ii) Infertility studies;

(iii) In vitro fertilization;

(iv) Artificial Insemination; and

(v) Surrogate motherhood, including all services, tests, and related charges.

(3) Anesthesia.

(a) Medicaid may only cover anesthesia services performed by a licensed, qualified provider.

(b) Medicaid does not cover anesthesia standby services.

(4) Surgical Services.

(a) Surgical procedures.

(i) Surgical services are global services. Global services include:

(b) preoperative examination, initiation of the hospital record, and development of a treatment program either in the physician's office on the day before admission, or in the hospital or the physician's office on the same day as hospital admission;

(d) any topical, local, or regional anesthesia; and

(e) the normal, uncomplicated follow-up care covering the period of hospitalization and office follow-up for progress checks or any service directly related to the surgical procedure.

(f) Interpretation of "global" services:

(i) A physician may not bill for an office visit the day before surgery, for preadmission or admission workup, or for subsequent hospital care while the patient is being prepared, hospitalized, or under care for a "global" surgical service;

(ii) Only the consulting physician may bill for consultation services when consultation and no other service is provided. When a consulting physician admits and follows a patient, independently or concurrently with the primary physician, the consulting physician may only use admission codes and subsequent care codes;

(iii) Office visits after hospitalization that relate to the same diagnosis are part of the global service. The only exception to either inpatient or office service is for service related to complications, exacerbations, or recurrence of other diseases or problems requiring additional or separate service.

(iv) Complications, exacerbations, recurrence, or the presence of other diseases or injuries, which require services concurrent with the initial surgical procedure during the listed period of normal follow-up care, may warrant additional charges only when the record shows extensive documentation and justification of additional services.

(v) When an additional surgical procedure is carried out within the listed period of follow-up care for a previous surgery, the follow-up periods continue concurrently to their normal terminations.

(vi) Preoperative examination and planning are covered as separate services only under the following circumstances:

(I) When the preoperative visit is the initial visit for the physician and prolonged detention or evaluation is required to establish a diagnosis to determine the need for a specific surgical procedure, or to prepare the patient;

(II) When the preoperative visit is a consultation and the consulting physician does not assume care of the patient; or

(III) When diagnostic procedures are not part of the basic surgical procedure.

(5) Maternity Care and Delivery.

(i) Medicaid does not cover early elective delivery, whether vaginal or caesarean, before 39 weeks.

(6) Abortion, Sterilization and Hysterectomy.

(i) For information on abortion policy, see Rule R414-1B.

(ii) Sterilization and hysterectomy procedures must meet the requirements of 42 CFR 441, Subpart F.

(7) Transplant Services.

(i) Organ transplant services must meet the requirements of Rule R414-10A.

(8) Medicine.

(a) Psychiatric Services. The following services may be covered as a medical benefit:

(i) Physician-ordered psychiatric services for a patient hospitalized in a non-psychiatric unit of a hospital;

(ii) Mental health services that target the diagnosis or treatment of developmental disability or organic disorder; and

(iii) Psychosocial evaluations requested before organ transplantations, psychiatric evaluations before other medical services or surgical procedures, and evaluations for individuals with conditions that require chronic pain management services.

(b) Pain Management Services.

(i) Medicaid covers pain management for delivery and acute postoperative pain.

(ii) Medicaid covers treatment for chronic pain.

(i) Medicaid may cover prescription medications subject to the requirements of Rule R414-60.

R414-10-6. Copayment Policy

Latest version.

Each Medicaid client is responsible to pay a copayment amount that complies with the requirements of the Utah Medicaid State Plan and Rule R414-1.