471 NAC 10-004. SERVICE REQUIREMENTS

004. SERVICE REQUIREMENTS. 004.01 General Requirements. 004.01(A) Medical Necessity. Services and supplies that do not meet the definition of medical necessity are not covered. The fact that the physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Nebraska Medicaid. Services and supplies which do not meet the definition of medical necessity set out above are not covered. Approval by the Food and Drug Administration (FDA) or similar approval does not guarantee coverage by Nebraska Medicaid. Licensure or certification of a particular provider type does not guarantee Nebraska Medicaid coverage. 004.01(B) Prior Authorization. Physicians must request prior authorization from Nebraska Medicaid before providing: (1) Medical transplants; (2) Abortions; (3) Cosmetic and reconstructive surgery; (4) Bariatric surgery for obesity; (5) Out-of-state services, except emergency services provided out-of-state ; (6) Established procedures of questionable current usefulness; (7) Procedures which tend to be redundant when performed in combination with other procedures; (8) New procedures of unproven value; (9) Certain drug products; (10) All attended sleep studies; and (11) Ventricular assist devices. 004.01(B)(i) Prior Authorization Procedures. The physician must request prior authorization for the services in the section above in writing. 004.01(B)(i)(1) Request for Additional Evaluations. Additional evaluations may be requested and must be provided when Nebraska Medicaid determines that the medical history for the request is questionable or when there is not sufficient information to support the requirements for authorization. 004.01(B)(i)(2) Notification Process. Upon determination of approval or denial, a written response is provided to the following, as applicable, and depending on the source of the request: (a) Physician(s) submitting or contributing to the request; (b) Caseworker or case manager; and (c) Medical review organization when appropriate. 004.01(B)(ii) Verbal Authorization Procedures. A verbal authorization may be issued when circumstances are of an emergency nature, or urgent to the extent that a delay would place the beneficiary at risk of not receiving medical care. When a verbal authorization is granted, a written request must be submitted within 14 days of the verbal authorization. 004.01(B)(iii) Billing and Payment Requirements. Claims submitted to Nebraska Medicaid for services requiring prior authorization will not be paid without written or electronic approval. A copy of the approval letter or notification of authorization issued by Nebraska Medicaid must be submitted with all claims related to the procedure or service authorized. 004.02 SPECIFIC REQUIREMENTS. 004.02(A) Services Provided for BENEFICIARIES Enrolled in Nebraska Medicaid. Certain Nebraska Medicaid beneficiaries are required to participate in the Nebraska Medicaid Managed Care Program . Services provided to beneficiaries enrolled in a managed care plan are not billed to Nebraska Medicaid . The provider must provide services only under arrangement with the managed care organization (MCO). The prior authorization requirements, payment limitations, and billing instructions outlined in this chapter do not apply to services provided to beneficiaries enrolled in a managed care plan with the following exceptions: (i) Transplants continue to require prior authorization by Nebraska Medicaid and are reimbursed on a fee-for-service basis, outside the managed care organization’s (MCO) capitation payment; (ii) Abortions require prior authorization by Nebraska Medicaid and are included in the capitation fee for the managed care organization (MCO); and (iii) The beneficiary must be able to obtain family planning services upon request and from any appropriate provider who is enrolled in Nebraska Medicaid. Family planning services are reimbursed by the managed care organization (MCO), regardless of whether the service is provided by a primary care provider (PCP) enrolled with the managed care organization (MCO) or a family planning provider outside the managed care organization (MCO). 004.02(B) Prior Authorization for Transplant Services. Transplant services are reimbursed on a fee-for-service basis. Prior authorization is required for all transplant services. Physicians must request prior authorization before performing any transplant service or related donor service. 004.02(B)(i) PRIOR AUTHORIZATION REQUIREMENTS. Prior authorization requests must include at a minimum: (1) The patient's name, Nebraska Medicaid identification number , and date of birth; (2) Diagnosis, pertinent past medical history and treatment, prognosis with and without the transplant, and the procedure(s) for which the authorization is requested; (3) Name of the hospital, city, and state where the service(s) will be performed, including the National Provider Identification number of the provider. All providers must be enrolled with Nebraska Medicaid before services are performed. ; (4) Name of the physician(s) who will perform the surgery if other than the physician requesting authorization; and (5) In addition to the above information, a physician specializing in the specific transplantation must also supply the following: (a) The screening criteria used in determining that a beneficiary is an appropriate candidate for the requested transplant; (b) The results of that screening for this beneficiary ; and (c) A written statement by the physician: (i) Recommending the transplant; (ii) Certifying and explaining why the transplant is medically necessary as the only clinical, practical, and viable alternative to prolong the beneficiary’s life in a meaningful, qualitative way and at a reasonable level of functioning; and (iii) Psycho-social evaluation for solid organ transplants, except for heart and liver transplants. A second physician specializing in the specific transplant must also supply a second written statement meeting the above criteria. 004.02(C) Prior Authorization for BARIATRIC Surgery. Prior authorization requests must include documentation of all of the following: (i) Medical diagnoses; (ii) Body mass index 35 or greater with one of the following co-morbidities: (1) Type 2 Diabetes Mellitus including recent lab results and current medications; (2) Medically refrectory hypertension including current medications, antihypertensive, and blood pressure readings; (3) Hyperlipidema including recent lab results and current medications; (4) Cardiovascular disease; (5) Coronary Artery Disease; (6) Obstructive sleep apnea including sleep study results and treatment; (7) Obesity-hypoventilation syndromes; (8) Gastroesophageal Reflux Disease including test results and current medications ; (9)Osteoarthritis including information about the beneficiary’s ability to ambulate, assistive devices used, and any medications ; or (10)Idiopathic intracranial hypertension pseudo tumor cerebri ; and (iii) Preoperative evaluation within six months of the scheduled surgery must include: (1) Nutritional consultation that includes: (a) Diet and physical activity history and patterns of previous weight loss and regain; (b) Counseling on steps to modify current problem eating behaviors; (c) Counseling on postoperative dietary modifications; and (d) Determination of the beneficiary’s motivation to comply with dietary modifications to reduce the risk of postoperative complications; (2) Psychiatry or psychology consultation that includes: (a) Evaluation of the beneficiary to determine readiness for surgery and lifestyle change; (b) Assessment for major mental health disorders, psychosocial functioning, alcohol and substance use disorder, and maladaptive eating behaviors; and (c) Adequate treatment as needed, to maximize successful postoperative outcomes; and (3) Medical clearance that includes: (a) Evaluation of cardiac and pulmonary risk; (b) Nutritional, hormonal, and other lab parameters as indicated; (c) No history of tobacco use, or tobacco cessation has been attempted prior to surgery; and (d) Beneficiary’s understanding of surgical risk, postoperative compliance, and follow-up. 004.03 Covered Inpatient Services. 004.03(A) Bed and Board. The same amount is paid for inpatient services whether the beneficiary has a private room, a semiprivate room, or ward accommodations. 004.03(B) Nursing Services. Nursing and other related services and use of hospital facilities for the care and treatment of inpatients are included in the hospital's payment for inpatient services. 004.03(C) Services of Interns and Residents-In-Training. The reasonable cost of the services of interns or residents-in-training are covered under a teaching program approved by the Council on Medical Education of the American Medical Association or, in the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association. 004.03(C)(i) Approved Programs for Podiatric Interns and Residents-In-Training. The services of interns and residents-in-training in the field of podiatry under a teaching program approved by the Council on Podiatry Education of the American Podiatry Association are covered under Nebraska Medicaid on the same basis as the services of other interns and residents-in-training in approved teaching programs. 004.03(C)(ii) Dental Interns and Residents-In-Training. For services of interns or residents-in-training in the field of dentistry in a hospital or osteopathic hospital, the teaching program must be approved by the Council of Dental Education of the American Dental Association. 004.03(D) Outpatient OR Emergency Services. When a beneficiary receives hospital outpatient or emergency room services and is thereafter admitted as an inpatient of the same hospital before midnight of the same day, the hospital outpatient or emergency room services are covered by Nebraska Medicaid as inpatient services. Hospital outpatient services furnished in the outpatient or emergency room to a beneficiary classified as dead on arrival are covered through pronouncement of death, providing the hospital considers these beneficiaries as outpatients for recordkeeping purposes and follows its usual outpatient billing practices for services to all patients. This coverage does not apply if the beneficiary was pronounced dead before arrival at the hospital. 004.03(E) Ancillary Services. Payment for the ancillary services described in this section is included in the payment for inpatient services. Outpatient services must be claimed using the appropriate national standard code sets. 004.03(F) Blood Administration. For beneficiaries who are receiving both Medicare and Nebraska Medicaid benefits, Nebraska Medicaid covers the first three pints of blood. Autologous blood donation processing costs are not covered for reimbursement by Nebraska Medicaid. Nebraska Medicaid covers any blood administration not covered by Medicare or other third-party insurance if it is medically necessary. Hospitals must distinguish between blood and blood processing costs under the following rules: (i) A hospital's blood costs will consist of amounts it spends to procure blood, including: (1) The cost of activities as soliciting and paying donors and drawing blood for its own blood bank; and (2) When a hospital purchases blood from an outside blood source an amount equal to the amount of credit which the outside blood source customarily gives the hospital if the blood is replaced. (ii) A hospital's blood processing costs consist of amounts spent to process and administer blood after it has been procured, including: (1) The cost of such activities as storing, typing, cross-matching, and transfusing blood; (2) The cost of spoiled or defective blood. This cost does not include blood that is spoiled or defective as a result of general storage expiration; and (3) The portion of the outside blood source's blood fee which remains after credit is given for replacement. 004.03(G) Personal Care Items. Personal care items are covered when they are necessary for the care of a beneficiary during inpatient or outpatient services. 004.03(H) LONG-TERM ACUTE CARE HOSPITAL (LTACH) SERVICES. Long-term acute care hospital (LTACH) admission may be considered when continued daily monitoring and complex medical intervention is required for the complex medical condition(s). Prior authorization is required for long-term acute care level of care (LOC) as follows: 004.04 Drugs. 004.04(A) Inpatient Drugs. Drugs for use in the hospital which are ordinarily provided by the hospital for the care and treatment of inpatients are covered. Payment for inpatient drugs is included in the hospital's payment for inpatient services. 004.04(B) Hospital Outpatient or Emergency Room Drugs. Drugs utilized in the actual treatment as part of the outpatient or emergency room service are covered. The hospital must bill drugs used in the outpatient or emergency room service by National Drug Code (NDC) on the appropriate Nebraska Medicaid approved health care claim form Providers must also report the quantity and unit of measure of the National Drug Code (NDC). Include the correct National Drug Code (NDC) information on all claims, including Medicare and other third-party claims. 004.05 Medical Supplies and Equipment. 004.05(A) Inpatient Supplies and Equipment. Supplies and equipment provided to inpatients for use during the inpatient stay are covered. These are included in the hospital's payment for inpatient services. Certain items used during the beneficiary’s inpatient stay are included in the hospital's payment for inpatient services even though they leave the hospital with the beneficiary . This includes items used in the actual treatment of the beneficiary which are permanently or temporarily inserted in or attached to the beneficiary’s body. 004.05(B) Hospital Outpatient and Emergency Room Supplies and Equipment. Medically necessary supplies and equipment used for outpatient and emergency room services are covered. This includes items used in the actual treatment of the beneficiary as well as items necessary to facilitate the beneficiary's discharge. 004.05(C) Take-Home Supplies and Equipment. The following supplies and equipment are covered: (1) Up to a ten-day supply of take-home supplies following an inpatient or outpatient service. Durable medical equipment must be billed by a recognized durable medical equipment provider with the exception of rental apnea monitors and home phototherapy units. 004.05(C)(i) Infant Apnea Monitors. Rental of home infant apnea monitors is covered for infants with medical conditions that require monitoring due to a specific medical diagnosis only if prescribed by and used under the supervision of a physician. Proper infant evaluation by the physician and parent or caregiver training must occur before placement of infant apnea monitor. Payment for hospital apnea monitoring services provided to an inpatient is included in the hospital payment for inpatient services. 004.05(C)(ii) PHOTOTHERAPY SERVICES. Phototherapy equipment is covered on a rental basis for infants that meet the following criteria: (a) Neonatal hyperbilirubinemia is the infant's sole clinical problem; (b) The infant is greater than or equal to 37 weeks gestational age and birth weight greater than 2,270 gm or five lbs.; (c) The infant is greater than 48 hours of age; (d) Bilirubin level at initiation of phototherapy greater than 48 hours of age is 14-18 mgs per deciliter. Home phototherapy is not covered if the bilirubin level is less than 12 mgs at 72 hours of age or older; and (e) Direct bilirubin level is less than two mgs per deciliter. 004.06 Laboratory and Pathology. 004.06(A) PROFESSIONAL COMPONENT. The professional component of laboratory services provided by a physician is covered to an individual patient in accordance with this title . The professional component must be billed on the appropriate Nebraska Medicaid approved health care claim form . 004.06(B) CLINICAL LAB SERVICES. Clinical laboratory services are considered technical components and must be billed as such. The technical component of clinical laboratory services provided to hospital inpatients, outpatients, and non-patients performed by non-physicians manually or using automated laboratory equipment is covered. Payment is made to the hospital as follows: (1) The hospital may include inpatient service costs on its cost report to be considered in calculating the hospital's payment rate. (2) Outpatient clinical laboratory services must be itemized on the appropriate claim form or electronic format using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure codes. Payment is made pursuant to the fee schedule determined by Centers for Medicare & Medicaid Services (CMS). (3) Payment is made pursuant to the fee schedule determined by Centers for Medicare & Medicaid Services (CMS) for non-patient services. 004.06(B)(i) LEASED DEPARTMENTS. Leased department status has no bearing on billing or payment for clinical lab services. The hospital must claim all clinical lab services, whether performed in a leased or non-leased department. Payment for the total service, which includes the professional and technical component, is made to the hospital. Separate payment is not made for the professional component for clinical lab services. 004.06(C) ANATOMICAL PATHOLOGY SERVICES. Anatomical pathology services require a physician's interpretation. If these services are provided to hospital inpatients or outpatients, the professional and technical components must be separately identified for billing and payment. There is no separate payment made to the pathologist for routine clinical lab services. To be paid, the pathologist must negotiate with the hospital to arrange a salary or compensation agreement. 004.06(C)(i) BILLING AND PAYMENT FOR HOSPITAL INPATIENT ANATOMICAL PATHOLOGY SERVICES. Payment for the technical component of anatomical pathology is included in the hospital's payment for inpatient services which is claimed on the appropriate claim form or electronic format as an ancillary service. The hospital may include these costs on its cost report to be considered in calculating the hospital's payment rate. The pathologist must claim the professional component of anatomical pathology on the appropriate Nebraska Medicaid approved health care claim form using the appropriate Healthcare Common Procedure System Procedure Code (HCPCS) and modifier . 004.06(C)(i)(1) EXCEPTION. If an anatomical pathology specimen is obtained from a hospital inpatient but is referred to an independent laboratory or the pathologist of a second hospital's laboratory, the independent lab or the pathologist of the second hospital's laboratory to which the specimen has been referred may claim payment for the total service on the appropriate Nebraska Medicaid approved health care claim form . 004.06(C)(ii) BILLING AND PAYMENT FOR HOSPITAL OUTPATIENT ANATOMICAL PATHOLOGY SERVICES. The hospital must bill the technical component of outpatient anatomical pathology services in a summary bill format using the appropriate revenue code on the appropriate claim form or electronic format. The pathologist must claim the professional component on the appropriate Nebraska Medicaid approved health care claim form using the appropriate Healthcare Common Procedure System Procedure Code (HCPCS) and modifier . 004.06(C)(ii)(1) EXCEPTION. If an anatomical pathology specimen is obtained from a hospital outpatient and is referred to an independent lab or the pathologist of a second hospital's laboratory, the independent lab or the pathologist of a second hospital's laboratory to which the specimen was referred may claim payment for the total service on the appropriate Nebraska Medicaid approved health care claim form . 004.06(C)(iii) BILLING AND PAYMENT FOR NON-PATIENT ANATOMICAL PATHOLOGY SERVICES. For specimens from non-patients referred to the hospital, the hospital must bill the total service on the appropriate claim form or electronic format using the appropriate revenue code. 004.06(C)(iv) LEASED DEPARTMENTS. If the pathology department is leased and an anatomical pathology service is provided to a hospital non-patient, the pathologist must claim the total service, which includes the professional and technical components, on the appropriate Nebraska Medicaid approved health care claim form . Leased department status has no bearing on billing for or payment for hospital inpatient or outpatient anatomical pathology services. 004.06(D) ADJUSTMENT BASED ON LEGISLATIVE APPROPRIATIONS. The starting point for the payment amounts must be adjusted by a percentage. This percentage will be determined by Nebraska Medicaid as required by the available funds appropriated by the Nebraska Legislature. 004.07 HOSPITAL DIAGNOSTIC AND THERAPEUTIC SERVICES. Hospital diagnostic and therapeutic services are procedures performed to determine the nature and severity of an illness or injury, or procedures used to treat disease or disorders. Hospital diagnostic and therapeutic services include both hospital inpatient and outpatient services. Hospital diagnostic and therapeutic services are comprised of two distinct elements: the professional component and the technical component. 004.07(A) TECHNICAL COMPONENT. The technical component of hospital diagnostic and therapeutic services is comprised of two distinct elements: (1) Physicians' professional services not directly related to the medical care of the individual beneficiary; and (2) Hospital services. 004.07(A)(i) INPATIENT TECHNICAL COMPONENT. Payment for the technical component of inpatient services is included in the hospital's payment for inpatient services whether provided directly or under arrangement with an outside provider. The hospital is responsible for payment of all services provided to an inpatient under arrangement by an outside provider, except ambulance services, to the outside provider for inpatient services, if the service is provided under arrangement. 004.07(A)(ii) OUTPATIENT AND NON-PATIENT TECHNICAL COMPONENT. The technical component of outpatient and non-patient services must be claimed by the provider actually providing the service. Nebraska Medicaid’s payment for the technical component includes payment for all non-physician services required to provide the procedure. 004.07(B) NON-PHYSICIAN SERVICES AND ITEMS. All non-physician services, drugs, medical supplies, and items, provided to hospital inpatients or outpatients must be provided directly by the hospital or under arrangements. If the services or items are provided under arrangements, the hospital is responsible for payment to the non-physician provider or supplier. The unbundling of costs by hospitals for non-physician services or supplies provided to hospital patients is prohibited, including ancillary services provided by another hospital. 004.08 RADIOLOGY. Medically necessary radiological services provided to inpatients and outpatients are covered. Only those services which are directly related to the beneficiary's diagnosis are covered and the provider must indicate the diagnosis which reflects the condition for which the service is performed on the claim from, and if necessary, include a notation on the claim which documents the need. A radiological laboratory is not considered an independent laboratory under Nebraska Medicaid. All radiology services have a technical component and a professional component, including physician interpretation. The professional and technical component of hospital services must be separately identified for billing and payment. 004.08(A) PROFESSIONAL COMPONENT. The professional component of radiology services provided by a physician to an individual beneficiary is covered in accordance with this chapter . 004.08(B) TECHNICAL COMPONENT. The technical component of hospital radiology services is covered. 004.08(C) MAMMOGRAMS. Diagnostic and screening mammograms are covered. Mammography services are covered only for providers who have met Medicare certification criteria for mammography services. 004.08(C)(i) SCREENING MAMMOGRAPHY. One screening mammogram is covered annually according to the periodicity schedule and guidelines of the American Cancer Society. 004.08(C)(ii) DIAGNOSTIC MAMMOGRAPHY. Diagnostic mammograms are covered based on the medical necessity of the service. 004.08(D) PORTABLE X-RAY SERVICES. Diagnostic x-ray services provided by a certified portable x-ray provider are covered when provided in a place of residence used as the beneficiary's home and in nonparticipating institutions. These services must be performed under the general supervision of a physician and certain conditions relating to health and safety must be met. 004.08(D)(i) COVERED PORTABLE X-RAY SERVICES. The following portable x-ray services are covered: (1) Skeletal films involving arms and legs, pelvis, vertebral column, and skull; (2) Chest films which do not involve the use of contrast media; and (3) Abdominal films which do not involve the use of contrast media. 004.08(D)(ii) SPECIAL NEEDS FACILITIES. Diagnostic portable x-ray services are covered when provided in participating special need facilities, under circumstances in which they cannot be covered as special need facilities services. If portable x-ray services are provided in a participating hospital under arrangement, the hospital must bill Nebraska Medicaid for the service. 004.08(D)(iii) ELECTROCARDIOGRAMS. The taking of an electrocardiogram tracing by an approved supplier of portable x-ray services can be covered as an other diagnostic test. The health and safety standards in this chapter must be met. 004.08(D)(iv) CERTIFIED PROVIDERS. Providers of portable x-ray services must be certified by the Centers for Medicare & Medicaid Services (CMS) . 004.08(D)(iv)(1) NEBRASKA PORTABLE X-RAY PROVIDER. The provider must submit the appropriate Nebraska Medicaid approved certification form . 004.08(D)(iv)(2) OUT-OF-STATE PORTABLE X-RAY PROVIDER. Nebraska Medicaid approves or denies enrollment based on verification of certification information received from the Centers for Medicare & Medicaid Services (CMS) . 004.08(D)(v) APPLICABILITY OF HEALTH AND SAFETY STANDARDS. Health and safety standards apply to all providers of portable x-ray services, except physicians who provide immediate personal supervision during the administration of diagnostic x-ray services. Payment is made only for services of approved providers who have been found to meet the standards. 004.08(D)(v)(1) CONDITIONS OF COVERAGE NOTIFICATION. When the services of a provider of portable x-ray services no longer meet the conditions of coverage, physicians responsible for supervising the portable x-ray services and having an interest in the x-ray provider's certification status must be notified. The notification action regarding suppliers of portable x-ray equipment is the same as required for decertification of independent laboratories, and the same procedures are followed. 004.08(E) RADIOLOGY FOR ANNUAL PHYSICAL EXAMS FOR BENEFICIARIES RESIDING IN NURSING FACILITIES AND INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). All long-term care facility (LTC) residents are required to have an annual physical examination. The physician, based on their authority to prescribe continued treatment, determines the extent of the examination for Nebraska Medicaid beneficiaries based on medical necessity. 004.08(F) BILLING AND PAYMENT FOR RADIOLOGY SERVICES. 004.08(F)(i) BILLING AND PAYMENT FOR HOSPITAL INPATIENT RADIOLOGY SERVICES. Payment for the technical component of inpatient radiology services is included in the hospital's payment for inpatient services. These costs may be included on the hospital's cost report to be considered in calculating the hospital's payment rate. Physicians must claim the professional component of inpatient radiology services on the appropriate Nebraska Medicaid approved health care claim form using the appropriate healthcare procedure code and modifier . 004.08(F)(ii) BILLING AND PAYMENT FOR HOSPITAL OUTPATIENT RADIOLOGY SERVICES. The hospital must claim the technical component of outpatient radiology services on the appropriate claim form or electronic format. Payment is made according to this chapter . The physician must claim the professional component on the appropriate Nebraska Medicaid approved health care claim form using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code and modifier . 004.08(F)(iii) BILLING AND PAYMENT FOR NON-PATIENT RADIOLOGY SERVICES. If a radiology procedure is performed for a non-patient, the hospital must claim the total component on the appropriate claim form or electronic format. 004.08(F)(iv) LEASED DEPARTMENTS. If the radiology department is leased and the service is provided to a non-patient, the radiologist must claim the total service - both technical and professional components, on the appropriate Nebraska Medicaid approved health care claim form . 004.09 OUTPATIENT DIAGNOSTIC SERVICES PROVIDED BY ARRANGEMENT. Medically necessary diagnostic services provided to an outpatient by arrangement. 004.09(A) Specimen Collection Fees. Separate charges made by laboratories for drawing or collecting specimens are allowable whether or not the specimens are referred to another hospital or laboratory for testing. This fee will be paid to the provider who extracted the specimen from the beneficiary. Only one collection fee is allowed for each type of specimen for each beneficiary encounter, regardless of the number of specimens drawn. When a series of specimens is required to complete a single test, the series is treated as a single encounter. A specimen collection fee is allowed for activities such as drawing a blood sample through venipuncture or collecting a urine sample by catheterization. 004.09(A)(i) SPECIMENS COLLECTED OUTSIDE OF THE HOSPITAL. A specimen collection fee is allowed when it is medically necessary for a laboratory technician to draw a specimen from a beneficiary who resides in a nursing facility or who is homebound. The technician must personally draw the specimen. A specimen collection fee is not allowed for a visiting technician when a beneficiary in a facility is not confined to the facility or when the facility has personnel on duty qualified to perform the specimen collection. 004.09(A)(ii) TRAVEL EXPENSES. The fees allowed for a visiting technician cover the travel expenses of the technician, as well as the specimen drawing service, and the material and supplies used. Exceptions to this rule may be made when it is clear that the payment is inequitable in light of the distances the technician must travel to perform the test for nursing home or homebound beneficiaries in rural areas. 004.09(A)(iii) NON-COVERED SERVICES. A specimen collection fee is not allowed for samples where the cost of collecting the specimen is minimal. 004.10 AMBULANCE SERVICES. A hospital-based ambulance service is an ambulance service owned and operated by a hospital. Providers of ambulance services must meet the licensure and certification requirements of the Department of Health and Human Services, Division of Public Health. Providers of hospital-based ambulance services must comply with all applicable requirements in this title. 004.10(A) BILLING FOR HOSPITAL-BASED AMBULANCE SERVICES. Hospital-based ambulance services provided to an inpatient or an outpatient must be claimed on the appropriate claim format or electronic format as a hospital outpatient service by the hospital-based ambulance provider. Hospital-based ambulance services are reimbursed as a hospital outpatient service. Hospital-based ambulance costs are not included in the calculations for hospital inpatient rates. 004.10(B) GROUND AMBULANCE SERVICES. Nebraska Medicaid covers basic life support and advanced life support ambulance services. Ground ambulance base rates include all services, equipment, and other costs. 004.10(B)(i) BASIC LIFE SUPPORT (BLS) AMBULANCE. A basic life support (BLS) ambulance provides transportation plus the equipment and staff needed for basic services . 004.10(B)(ii) ADVANCED LIFE SUPPORT (ALS) SERVICES. An advanced life support (ALS) ambulance provides transportation and has complex specialized life-sustaining equipment and equipment for radio-telephone contact with a physician or hospital. . 004.10(C) MILEAGE. Miles traveled while the beneficiary is present in the ambulance vehicle is covered for out-of-town ambulance transports. Out-of-town transports are defined as trips in which the final destination of the beneficiary is outside the limits of the town in which the trip originated. Mileage traveled while the beneficiary is not present in the ambulance vehicle is included in the payment for the base rate. 004.10(D) THIRD ATTENDANT. A third attendant is covered only if the circumstances of the transport requires three attendants. The circumstances which required the third attendant must be documented on or with the claim when billing Nebraska Medicaid. Payment for a third attendant cannot be made when the third attendant is: (i) Needed because a crew member is not qualified to provide a service; or (ii) Staff provided by the hospital to accompany a beneficiary during transport. 004.10(E) WAITING OR STANDBY TIME. Waiting or standby time is separately reimbursed only when unusual circumstances exist. The unusual circumstances including why the ambulance waited and where the wait took place must be documented on or with the claim when billing Nebraska Medicaid. When waiting time is covered, the first one-half hour is not reimbursed. Payment for waiting time under normal circumstances is included in the payment for the base rate. 004.10(F) AIR AMBULANCE. Medically necessary air ambulance services are covered only when transportation by ground ambulance is contraindicated and: (1) Great distances or other obstacles are involved in getting the beneficiary to the destination; (2) Immediate and rapid admission is essential; or (3) The point of pickup is inaccessible by land vehicle. 004.10(F)(i) BILLING. When billing Nebraska Medicaid, the provider must bill air ambulance services as a single charge which includes base rate and mileage. The number of miles traveled while the beneficiary is present must be included on the claim. If a determination is made that ambulance transport is medically necessary, but ground ambulance would have been appropriate, payment for the air ambulance service is limited to the amount allowable for ground transport. 004.10(G) LIMITATIONS AND REQUIREMENTS FOR CERTAIN AMBULANCE SERVICES. 004.10(G)(i) EMERGENCY AND NON-EMERGENCY TRANSPORTS. Emergency transports are defined as services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in: (a) Placing the beneficiary’s health in serious jeopardy; (b) Serious impairment to bodily functions; or (c) Serious dysfunction of any bodily organ or part. 004.10(G)(i)(1) NON-EMERGENT TRANSPORT. Any ambulance transport that does not meet the definition of an emergency transport must be billed as a non-emergency transport. This includes all scheduled runs regardless of origin and destination and transports to nursing facilities or to the beneficiary’s home. 004.10(G)(ii) TRANSPORTS TO THE FACILITY WHICH MEETS THE NEEDS OF THE BENEFICIARY . Ambulance services are covered to enable the beneficiary to obtain medical care in a facility or from a physician or practitioner that most appropriately meets the needs of the beneficiary , including: (1) Support from the beneficiary’s community or family; or (2) Care from the beneficiary’s own physician, practitioner, or a qualified physician or practitioner or specialist. 004.10(G)(iii) TRANSPORTS TO A PRACTITIONER'S OFFICE, CLINIC, OR THERAPY CENTER. Emergency ambulance transports to a physician or practitioner's office, clinic, or therapy center are covered. Non-emergency ambulance transports to a physician or practitioner's office, clinic, or therapy center are covered when: (1) The beneficiary is bed confined before, during, and after transport; and (2) The services cannot reasonably be expected to be provided at the beneficiary’s home including a nursing facility or intermediate care facilities for individuals with developmental disabilities (ICF/DD). 004.10(G)(iv) ROUND TRIP TRANSPORTS FOR HOSPITAL INPATIENTS. Ambulance services provided to a beneficiary receiving hospital inpatient services, where the beneficiary is transported to another facility for services and the beneficiary is returned to the originating hospital for continuation of inpatient care, are not included in the payment to the hospital for inpatient services and must be billed by the hospital-based ambulance provider. 004.10(G)(v) COMBINED ADVANCED LIFE SUPPORT (ALS) AND BASIC LIFE SUPPORT (BLS) TRANSPORTS. When a beneficiary is transferred from a basic life support (BLS) ambulance to an advanced life support (ALS) ambulance, the advanced life support (ALS) service may be billed, however only one ambulance provider may submit the claim for the service. 004.10(G)(v)(1) ADVANCED LIFE SUPPORTS (ALS) BILLING. When the placement of advanced life support (ALS) personnel and equipment on board a basic life support (BLS) ambulance qualifies the basic life support (BLS) ambulance as an advanced life support (ALS) ambulance, the advanced life support (ALS) service may be billed. 004.10(G)(vi) TRANSPORT OF MORE THAN ONE BENEFICIARY . When more than one beneficiary is transported during a single trip, a base rate is covered for each beneficiary transported. The number of miles and mileage charges must be prorated among the number of beneficiaries being billed. A notation that the mileage is prorated and why must be on or with the claim when billing Nebraska Medicaid. 004.10(G)(vii) TRANSPORT OF MEDICAL TEAMS. Transport of a medical team or other medical professionals to meet a beneficiary is not separately reimbursed. If the transport of the medical team results in an ambulance transport of the beneficiary , the services are included in the base rate of the beneficiary’s transport. 004.10(G)(viii) TRANSPORT OF DECEASED BENEFICIARIES . Ambulance services are covered if the beneficiary is pronounced dead while in route to or upon arrival at the hospital. Ambulance services are not covered if a beneficiary is pronounced dead before the beneficiary is transported. 004.11 PRE-ADMISSION TESTING. Pre-admission testing and diagnostic services rendered up to three days before the day of admission are covered, as an ancillary service. 004.11(A) NON-COVERED TESTING. Pre-admission testing is not covered when performed in a physician's office or as an outpatient which is performed solely to meet hospital pre-admission requirements. 004.12 HOSPITAL ADMISSION DIAGNOSTIC PROCEDURES. In addition to meeting medical necessity requirements, the major factors which are considered to determine that a diagnostic procedure performed as part of the admitting procedure to a hospital is reasonable and medically necessary are: (A) The test is specifically ordered by the attending physician, or a hospital staff physician responsible for the beneficiary when there is no admitting physician ; (B) The test is medically necessary for the diagnosis or treatment of the individual beneficiary's condition; and (C) The test does not unnecessarily duplicate: (i) The same test performed on an outpatient basis before admission; or (ii) The same test performed in connection with a separate, but recent, hospital admission. 004.13 THERAPEUTIC SERVICES. Therapeutic services, that a hospital provides to an inpatient or outpatient are those services which are incidental to the services of the physicians in the treatment of beneficiaries. Covered therapeutic services to hospital inpatients or outpatients include the services of therapists and equipment necessary for therapeutic services. 004.13(A) COVERED SERVICES – PHYSICAL THERAPY (PT), OCCUPATIONAL THERAPY (OT), AND SPEECH-LANGUAGE PATHOLOGY SERVICES. Physical therapy (PT), occupational therapy (OT), speech-language pathology, and audiology services are covered in accordance with this title. 004.13(B) RESPIRATORY THERAPY. Respiratory therapy is covered when provided by a respiratory therapist or technician in accordance with the conditions and criteria outlined in this title . 004.14 ANESTHESIOLOGY. 004.14(A) PROFESSIONAL COMPONENT. The professional component of anesthesiology services provided by a physician to an individual beneficiary is covered in accordance with this title . Rural hospitals that have been exempted by their Medicare fiscal intermediary for certified registered nurse anesthetist (CRNA) billing must follow the Medicare billing requirements. 004.14(A)(i) MEDICAL DIRECTION OF FOUR OR FEWER CONCURRENT PROCEDURES. The professional component for the physician's personal medical direction of concurrent anesthesiology services provided by qualified anesthetists is covered, such as certified registered nurse anesthetists (CRNA), in accordance with this chapter . The professional component of personal services up to and including induction is covered as a physician's service and must be billed on the appropriate Nebraska Medicaid approved health care claim form . 004.14(B) TECHNICAL COMPONENT. If the physician leaves the immediate area of the operating suite for longer than short durations, devotes extensive time to an emergency case, or is otherwise not available to respond to the immediate needs of surgical , beneficiaries the physician's services to the surgical beneficiary are supervisory in nature and are considered a technical component. 004.14(B)(i) MEDICAL DIRECTION OF MORE THAN FOUR CONCURRENT PROCEDURES. If the physician is involved in providing direction for more than four concurrent procedures or is performing other services while directing the concurrent procedures, the concurrent anesthesia services are covered as the technical component of the hospital services. The physician must ensure that a qualified individual performs any procedure in which the physician does not personally participate. 004.14(C) STANDBY ANESTHESIA SERVICES. A physician's standby anesthesia services are covered when the physician is physically present in the operating suite, monitoring the beneficiary’s condition, making medical judgments regarding the beneficiary's anesthesia needs and ready to furnish anesthesia services to a specific beneficiary who is known to be in potential need of services. The professional component must be billed on the appropriate Nebraska Medicaid approved health care claim form . 004.14(D) CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA). The hospital may engage the services of a certified registered nurse anesthetist (CRNA), either on a salary or fee-for-service basis, under arrangements which provide for billing to be made by the hospital. Reimbursement for the service when provided to an inpatient or outpatient is included in the payment rate under Nebraska Medicaid. 004.15 OUTPATIENT SURGICAL PROCEDURE. When a beneficiary with a known diagnosis enters a hospital for a specific surgical procedure or other treatment that is expected to keep the beneficiary in the hospital for less than 24 hours, and this expectation is realized, the beneficiary will be considered an outpatient regardless of the hour of admission; whether or not the beneficiary used a bed; and whether or not the beneficiary remained in the hospital past midnight. If the beneficiary receives 24 or more hours of care, the beneficiary is considered an inpatient regardless of the hour of admission or whether the beneficiary remained in the hospital past midnight or the census-taking hour. 004.16 OUTPATIENT OBSERVATION SERVICES. A maximum of 48 hours of outpatient observation is covered. After 48 hours, the beneficiary must either be admitted as an inpatient, by written order, or discharged. 004.17 HOSPITAL DENTAL SERVICES. Dental care and oral surgery are effectively provided in an office setting. Dental services may be provided in a hospital or ambulatory surgical center (ASC) when the beneficiary has medical or behavioral conditions that warrant these settings to maintain beneficiary safety. These services must be provided, billed, and reimbursed in accordance with the provisions of this title . 004.18 OTHER ANCILLARY SERVICES. 004.18(A) EMERGENCY ROOM PHYSICIANS' SERVICES. The hospital must bill Nebraska Medicaid for emergency room physicians' services on the appropriate Nebraska Medicaid approved health care claim form using the physician's provider number. 004.18(B) DIALYSIS SERVICES. Both hemodialysis and peritoneal dialysis are covered as acceptable modes for treatment of end stage renal disease. 004.18(B)(i) INPATIENT DIALYSIS SERVICES. Dialysis services provided to a beneficiary who is an inpatient are considered to be inpatient services. 004.18(B)(ii) OUTPATIENT DIALYSIS SERVICES. Outpatient dialysis services are those dialysis services provided to a beneficiary who is an outpatient. Outpatient dialysis services must be provided by a Medicare certified renal dialysis facility. 004.18(B)(iii) PAYMENT FOR OUTPATIENT DIALYSIS SERVICES. Outpatient dialysis services are reimbursed at the provider's current Medicare composite rate for the services provided. Payment excludes the cost of physician services.