R414-2A-6. Service Coverage

  (1) Inpatient hospital services must be medically necessary and ordered by an appropriate Medicaid-enrolled provider for the diagnosis and treatment of a member's illness.

  (2) Services performed for a member by the admitting hospital or by an entity wholly-owned or wholly-operated by the hospital within three days of patient admission, are considered inpatient services. This three-day window applies to diagnostic and non-diagnostic services that are clinically related to the reason for the member's inpatient admission regardless of whether the inpatient, outpatient, or observation diagnoses are the same.

  (3) Medical supplies, appliances, drugs, and equipment required for the care and treatment of a member during an inpatient stay are included in the inpatient reimbursement.

  (4) Outpatient hospital services during an inpatient episode are included in the inpatient reimbursement.

  (5) Inpatient hospital psychiatric services are available to all Medicaid members. If the member is not enrolled in a PMHP, providers may bill the State directly on a fee-for-service basis. Otherwise, the provider must bill the member's PMHP.

  (6) Inpatient hospital intensive physical rehabilitation services must meet the classification criteria of 42 CFR 412.29.

  (7) Inpatient hospital intensive physical rehabilitation services are covered for acute conditions from birth through any age and are available one time per event.