471 NAC 10-006. LIMITATIONS AND REQUIREMENTS FOR CERTAIN SERVICES

006. LIMITATIONS AND REQUIREMENTS FOR CERTAIN SERVICES. 006.01 PRIOR AUTHORIZATION PROCEDURES. The physician must request prior authorization in writing or through the appropriate electronic request prior to providing the service described in this chapter. 006.02 HIV TESTING FOR ACQUIRED IMMUNE DEFICIENCY SYNDROME. Payment for HIV testing is limited to medical necessity. 006.02(A) NON-COVERED HIV TESTING. HIV testing is not covered when there is no history of risk as defined in this chapter . This includes the following: (i) Routine prenatal screening; (ii) Routine pre-operative testing; (iii) Educational or employment requirements; (iv) Entrance requirements for the armed services; and (v) Insurance applications. 006.03 MINOR SURGICAL PROCEDURES. Reimbursement for excision of lesions of the skin or subcutaneous tissues includes all services and supplies necessary to provide the service. Nebraska Medicaid does not make additional reimbursement for suture removal to the physician who performed the initial service or to a hospital. If the sutures are removed by a non-hospital-based physician who is not the physician who provided the initial service, Nebraska Medicaid may approve separate payment for the suture removal. 006.04 TREATMENT FOR OBESITY. Services provided when the sole diagnosis is obesity will not be covered. While obesity is not itself considered an illness, there are conditions which can be caused by or aggravated by obesity. Treatment for obesity can be covered when the services are an integral and necessary part of a course or treatment. 006.04(A) INTESTINAL BY-PASS SURGERY. This procedure is not considered to be reasonable and necessary and it is not covered . 006.04(B) BARIATRIC SURGERY FOR OBESITY. Bariatric surgery for beneficiaries with extreme obesity can be covered when the surgery is: (1)Medically appropriate for the beneficiary; and (2)Performed to correct an illness which caused the obesity or was aggravated by the obesity. 006.04(B)(i) COVERAGE CONDITIONS. This procedure must be performed at a facility that is accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) or a children’s hospital that has a comprehensive multidisciplinary bariatric surgery program and provides access to an experienced surgeon who employs a team that is capable of long-term follow-up of the metabolic and psychosocial needs of the beneficiary and family. Proof of accreditation must be submitted with each prior approval request. 006.05 COSMETIC AND RECONSTRUCTIVE SURGERY. Cosmetic and reconstructive surgical procedures and medical services are covered when medically necessary for the purpose of correcting the following conditions: (i) Limitations in movement of a body part caused by trauma or congenital conditions; (ii) Disfiguring or painful scars in areas that are visible; (iii) Congenital birth anomalies that result in functional impairment or are severely disfiguring; (iv) Post-mastectomy breast reconstruction; and (v) Other procedures determined to be restorative or necessary to correct a medical condition. 006.05(A) EXCEPTIONS. To determine the medical necessity of the condition, prior authorization for cosmetic and reconstructive surgical procedures is required except for the following conditions:. (i) Cleft lip and cleft palate; (ii) Post-mastectomy breast reconstruction; (iii) Congenital hemangioma's of the face; and (iv) Nevus removals. 006.06 STERILIZATIONS. 006.06(A) COVERAGE RESTRICTIONS. Payment for sterilization of beneficiaries is prohibited when the beneficiary is : (i) Under the age of 21 on the date the beneficiaries is prohibited when the beneficiary is signs the appropriate Nebraska Medicaid approved consent form ; or (ii) Legally incapable of consenting to sterilization. 006.06(B) COVERAGE CONDITIONS. Sterilizations are only covered when: (i) The sterilization is performed because the beneficiary receiving the service made a voluntary request for services; (ii) The beneficiary is advised at the outset and before the request or receipt of their consent to the sterilization that benefits provided by programs or projects will not be withdrawn or withheld because of a decision not to be sterilized; (iii) Beneficiaries whose primary language is other than English must be provided with the required elements for informed consent in their primary language; and (iv) Suitable arrangements must be made to communicate the required elements of informed consent to a beneficiary who is blind, deaf or hard of hearing, or otherwise disabled. 006.06(C) PROCEDURE FOR OBTAINING SERVICES. Non-therapeutic sterilizations are covered by Nebraska Medicaid only when: (1) Legally effective informed consent is obtained on the appropriate Nebraska Medicaid approved consent form from the beneficiary on whom the sterilization is to be performed. The surgeon must submit a properly completed and legible appropriate Nebraska Medicaid approved consent form to Nebraska Medicaid before payment of claims can be considered; and (2) The sterilization is performed at least 30 days following the date informed consent was given. To calculate this time period, day one is the first day following the date on which the form is signed by the beneficiary . Day 31 in this period is the first day on which the procedure could be covered by Nebraska Medicaid. The consent is effective for 180 days from the date the appropriate Nebraska Medicaid approved consent form is signed. 006.06(C)(i) EXCEPTION. A beneficiary may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery, if at least 72 hours have passed since the beneficiary signed the informed consent for the sterilization. For a premature delivery, the beneficiary must have signed the informed consent at least 72 hours before the surgery is performed and at least 30 days before the expected date of delivery; the expected delivery date must be entered on the appropriate Nebraska Medicaid approved consent form . 006.06(C)(ii) INFORMED CONSENT. Informed consent means the voluntary, knowing assent of the beneficiary who is to be sterilized after the beneficiary has been given the following information: (a) A clear explanation of the procedures to be followed; (b) A description of the attendant discomforts and risks that may follow the procedure, including an explanation of the type and possible effects of an anesthetic to be used; (c) A description of the benefits to be expected; (d) Counseling concerning appropriate alternative methods, and the effect and impact of the proposed sterilization including the fact that it must be considered an irreversible procedure; (e) An offer to answer any questions concerning the procedures; (f) An instruction that the beneficiary is free to withhold or withdraw their consent to the sterilization at any time before the sterilization without prejudicing future care and without loss of other project or program benefits to which the beneficiary might otherwise be entitled; (g) Advice that the sterilization will not be performed for at least 30 days, except under circumstances previously specified ; and (h) The beneficiary to be sterilized must be permitted to have a witness of her or his choice present when informed consent was obtained. 006.06(C)(ii)(1) BENEFICIARY RESPONSIBILITY. The required informed consent information is shown on the appropriate Nebraska Medicaid approved consent form , which must be completed by the beneficiary . 006.07 HYSTERECTOMIES. For payment of claims for hysterectomies, the surgeon must submit to Nebraska Medicaid the appropriate Nebraska Medicaid approved consent form , properly signed and dated by the woman in which the woman states that they were informed before the surgery was performed that this surgical procedure results in permanent sterility before claims associated with the hysterectomy can be considered. The completed appropriate Nebraska Medicaid approved consent form must be submitted to Nebraska Medicaid, by the surgeon before claims for the hysterectomy can be considered for payment. A medically necessary hysterectomy will be covered if the following conditions have been met: (i) The provider who secured authorization to perform the hysterectomy has informed the woman and her representative, if any, orally and in writing, that the hysterectomy will make the woman permanently incapable of reproducing; and (ii) The woman or her representative, if any, has signed the appropriate Nebraska Medicaid approved consent form acknowledging receipt of that information. 006.07(A) EXCEPTION. Informed consent is not required if: (1) The woman was already sterile before the hysterectomy and the physician who performs the hysterectomy certifies in writing that the woman was already sterile before the hysterectomy and states the cause of the sterility; (2) In the case of a post-menopausal woman, Nebraska Medicaid considers the woman to be sterile. All claims related to the procedure must indicate that the woman is post-menopausal; or (3) The woman requires a hysterectomy because of a life-threatening emergency situation in which the physician determines that informed consent is not possible, and the physician who performs the hysterectomy certifies in writing that the hysterectomy was performed under a life-threatening emergency situation in which the physician determined informed consent was not possible. The physician must also include certification of the emergency. 006.07(A)(i) EXCEPTION CERTIFICATION. A copy of the physician's certification regarding the above exceptions must be submitted to Nebraska Medicaid before consideration for payment for claims associated with the hysterectomy can be submitted. 006.07(B) NON-COVERED HYSTERECTOMIES. A hysterectomy will not be covered if: (i) It was performed solely to make the woman sterile; or (ii) If there was more than one purpose for the procedure, it would not have been performed except to make the woman sterile. 006.08 ABORTIONS. Abortions are covered when the life of the mother would be endangered if the fetus were carried to term for which federal financial participation is currently available under federal regulations and the Nebraska Medicaid State Plan. A physician must certify the diagnosis by medical reports which include the name and address of the mother . The treating physician must request and receive prior authorization from Nebraska Medicaid before providing the service . If approved, a letter of authorization will be sent to the provider . In cases of documented emergencies, authorization may be requested after the service has been provided. All other requirements of this subsection must be met. 006.09 INFERTILITY. Coverage for infertility is covered to diagnosis and treat medical conditions when infertility is a symptom of a suspected medical problem. Reimbursement or coverage is not available when the sole purpose of the service is achieving a pregnancy. 006.10 LABOR AND DELIVERY. Reasonable and necessary services associated with pregnancy are covered. Medical care for pregnancy is reimbursable, beginning with diagnosis of the condition, continuing through delivery, and ending after the necessary postnatal care, or termination of pregnancy. Postpartum services are covered through the applicable postpartum period as defined in this chapter for women who were eligible for, applied for, and received medical assistance on the day the pregnancy ends. After the infant is delivered, the infant is treated as a separate patient for reimbursement purposes. 006.10(A) PHYSICIANS’ SERVICES. Routine prenatal care, delivery, post-partum care, and routine urinalysis are covered as a package service for physicians in accordance with this title . Hospitals will not be reimbursed for any physicians' services included in the package service. 006.10(B) EXCEPTIONS. Exceptions may be made to cover hospital outpatient or emergency room services which meet the coverage criteria for medically necessary services which are not included in the physicians' package service. 006.10(C) INPATIENT. If the beneficiary is admitted as an inpatient, and not released the same day, the services are considered inpatient services. If the beneficiary is not admitted as an inpatient, the services are considered outpatient services. 006.11 ALCOHOL AND CHEMICAL DETOXIFICATION. Payment for alcohol and chemical detoxification is limited to medically necessary treatment, subject to Nebraska Medicaid’s utilization review (UR). This coverage period includes up to five days as the beneficiary's condition dictates. A detoxification program for a particular beneficiary may exceed five days and be covered if determined medically necessary by Nebraska Medicaid. Services when the detoxification needs of a beneficiary no longer require an inpatient hospital setting are not covered. 006.12 OSTEOGENIC STIMULATION. Electrical stimulation to augment bone repair can be performed either invasively or non-invasively. 006.12(A) INVASIVE OSTEOGENIC STIMULATION. Use of the invasive device is covered only for non-union of long bone fractures. Non-union is considered to exist only after six months or more have elapsed without the fracture healing. 006.12(B) NON-INVASIVE OSTEOGENIC STIMULATION. Use of the non-invasive device is covered only for: (i) Non-union of long bone fractures; (ii) Failed fusion; and (iii) Congenital pseudarthrosis. 006.13 BIOFEEDBACK THERAPY. Biofeedback therapy is covered only when it is reasonable and necessary for the individual beneficiary for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, and more conventional treatments have not been successful. This therapy is not covered for treatment of ordinary muscle tension states, for psychosomatic conditions, or for psychiatric conditions. 006.14 DIAGNOSTIC SERVICES. All reasonable and necessary diagnostic tests given for narcolepsy and sleep apnea are covered when the following criteria are met: (i) The clinic is affiliated with a hospital; (ii) Beneficiaries are referred to the sleep disorder clinic by a physician. The clinic must maintain a record of the attending physician's orders with signatures; and (iii) The need for diagnostic testing is confirmed by medical evidence. 006.14(A) DUPLICATE TESTING. Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the results are still pertinent is not covered. Most beneficiaries who undergo the diagnostic testing are not considered inpatients, although they may come to the facility in the evening for testing and then leave after their tests are over. The overnight stay is considered an integral part of these tests. 006.15 THERAPEUTIC SERVICES. Therapeutic services may be covered provided they are standard and accepted services, and are reasonable and medically necessary for the beneficiary. Sleep disorder clinics must provide therapeutic services in the hospital outpatient setting. Therapeutic services will be provided for: (A) Insomnia that is not associated with psychiatric disorders; (B) Nocturnal myoclonus; (C) Sleep apnea; (D) Drug dependency; (E) Shift work and schedule disturbances; (F) Restless leg syndrome; (G) Hypersomnia; (H) Somnambulism; (I) Night terrors or dream anxiety attacks; (J) Enuresis; and (K) Bruxism. 006.16 CARDIAC STRESS TESTING AND HOSPITAL OUTPATIENT CARDIAC REHABILITATION PROGRAMS. Stress testing is a covered diagnostic procedure for evaluating chest pain and as a component in the development of rehabilitation exercise prescriptions for the treatment of beneficiaries with known cardiac disease provided that during the testing: (i) A physician is present; (ii) Emergency equipment is available; and (iii) A standard emergency procedure plan is in effect. 006.16(A) STRESS TESTING. The use of stress testing in the absence of any specific diagnostic or therapeutic purpose is not covered as reasonable and necessary to the treatment of the beneficiary's condition. 006.16(B) OUTPATIENT. Outpatient cardiac rehabilitation programs consist of individually prescribed physical exercise or conditioning and concurrent telemetric monitoring. When a program is provided by a hospital to its outpatients, the service is covered as an outpatient service. 006.16(B)(i) CARDIAC REHABILITATION EXERCISE PROGRAM. Hospital outpatient services in connection with a cardiac rehabilitation exercise program are considered reasonable and necessary only during that period of time when the beneficiary's condition is such that the exercises can only be carried out safely under the direct, continuing supervision of a physician, and in a hospital environment. The monitoring required in these programs must be carried out by a hospital-employed nurse trained in cardiac rehabilitation with a physician overseeing the monitoring. Although on occasion physical therapists (PT) or occupational therapists (OT) are involved in these programs, they generally act only as exercise leaders. These services do not constitute covered physical therapy (PT) or occupational therapy (OT). Since the type of cardiac rehabilitation exercise program which can be covered requires a hospital setting, this program is not covered in a skilled nursing facility (SNF). 006.16(B)(ii) COVERAGE LIMIT. Coverage is limited to 12 weeks or 36 sessions of a monitored exercise program. For coverage beyond a maximum duration of 12 weeks or 36 sessions, the provider must submit documentation supporting the beneficiary's need for additional services. Documentation must include: (1) Progress report and exercise sessions; (2) Diagnosis; (3) Cardiac history; (4) Risk factors; (5) Other medical problems; (6) Medications; (7) Allergies; (8) Personal habits; (9) Sources of stress, and support system; and (10) Treatment plan. 006.17 MEDICAL TRANSPLANTS. Transplants including donor services that are medically necessary and defined as non-experimental by Medicare are covered. If no Medicare policy exists for a specific type of transplant, it will be determined whether the transplant is medically necessary or non-experimental. Transplantation services are covered when performed in a facility approved by Centers for Medicare & Medicaid Services (CMS) as meeting coverage criteria. 006.17(A) PRIOR AUTHORIZATION. Prior authorization of all transplant services or related donor service is required before the services are provided. An exception may be made for emergency situations, in which case verbal approval is obtained and the notification of authorization is sent later. This request for authorization must be submitted in writing or using the standard electronic request form The physician must submit the request for authorization to Nebraska Medicaid in writing or using the standard electronic request form. The Prior Authorization request must include at a minimum: (i) The beneficiary's name, age, diagnosis, pertinent past medical history and treatment to this point, prognosis with and without the transplant, and the procedure(s) for which the authorization is requested; (ii) The beneficiary's Nebraska Medicaid number; (iii) Name of hospital, city, and state where the service(s) will be performed; and (iv) Name of physician(s) who will perform the surgery, if other than physician requesting authorization: (1) If authorization is requested for a liver or heart transplant, in addition to the above information, two physicians must also submit a statement recommending the transplant; and (2) Certifying and explaining why a 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. 006.17(B) SERVICES FOR A NEBRASKA MEDICAID-ELIGIBLE DONOR. Medically necessary services, including laboratory tests directly related to the transplant are covered, for the Nebraska Medicaid-eligible donor to a Nebraska Medicaid-eligible beneficiary . The services must be directly related to the transplant. 006.17(C) SERVICES FOR A NEBRASKA MEDICAID-INELIGIBLE DONOR. Medically necessary services, including laboratory tests directly related to the transplant, for the Nebraska Medicaid-ineligible donor to a Nebraska Medicaid-eligible beneficiary are covered . The services must be directly related to the transplant and must directly benefit the Nebraska Medicaid transplant beneficiary . Coverage of treatment for complications related to the donor is limited to those that are reasonably medically foreseeable. Claims must be submitted under the Nebraska Medicaid-eligible beneficiary’s case number. 006.17(D) ADDITIONAL RECORDS REQUEST. Nebraska Medicaid reserves the right to request any medical documentation from the beneficiary’s record to support and substantiate claims submitted for payment. 006.17(E) PAYOR OF LAST RESORT. Nebraska Medicaid is the payor of last resort. 006.17(F) HOSPITAL INPATIENT SERVICES. Procurement costs include removal of organ, transportation, and associated costs. These costs must be billed by the transplanting hospital on the appropriate claim form or electronic format and separately identified on the Medicare cost report. The hospital must submit copies of the actual invoices for procurement costs, including transportation costs, on the appropriate claim form or electronic format. 006.17(G) Ambulatory Room and Board. Ambulatory room and board services may be covered for transplant patients and an attendant if necessary. 006.18 PHYSICIAN SERVICES. Surgeon(s) services will be paid according to the Nebraska Medicaid Practitioner Fee Schedule. This fee will include two weeks' routine post-operative care by the designated primary surgeon. Payment for routine post-operative care will not be made to other members of the surgical team. Physician services must be billed on the appropriate Nebraska Medicaid approved claim form 006.19 ITINERANT PHYSICIAN VISITS. Non-emergency physician visits provided in a hospital outpatient setting are covered if the services are: (i) Provided by an out-of-town specialist who has a contractual agreement with the hospital. General practitioners or family practitioners are not considered to be specialists; and (ii) Determined to have been provided in the most appropriate place of service. 006.19(A) BILLING TECHNICAL COMPONENT. The hospital room charge is considered the technical component of the visit and must be billed on the appropriate Nebraska Medicaid approved claim form . 006.20 INFANT APNEA MONITORS. Rental of home infant apnea monitors for infants with medical conditions that require monitoring due to a specific medical diagnosis is covered 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. Parent or caregiver training is not reimbursed as a service separate from infant apnea monitor rental. 006.20(A) MEDICAL GUIDELINES FOR THE PLACEMENT OF HOME INFANT APNEA MONITORS. Home infant apnea monitoring services for infants, defined as birth through completion of one year of age, who meet one of the following criteria are covered according to criteria under this title. ; 006.20(B) APPROVAL OF HOME INFANT APNEA MONITOR SERVICE PROVIDERS. Rental of home infant apnea monitors and related supplies provided only by approved providers is covered. To ensure all home apnea monitoring needs of infants are met, the development of a home infant apnea monitor coordination plan is required. The coordination plan is not an individual patient plan; it is an overall program outline for the delivery of home apnea monitoring services. 006.20(C) DOCUMENTATION REQUIRED AFTER INITIAL RENTAL PERIOD. Monitor rental exceeding the first two-month prescription period requires that an updated physician's narrative report of the beneficiary progress and a statement of continued need accompany the claim. A new progress report is required every two months. The report must include: (i) The number of apnea episodes during the previous prescription period; (ii) The results of any tests performed during the previous prescription period; (iii) Additional length of time needed; and (iv) Any additional information the physician may wish to provide. 006.20(D) REMOVING THE INFANT FROM THE MONITOR. Criteria for removing infants from home infant apnea monitoring must be based on the infant's clinical condition. A monitor may be discontinued when apparent life-threatening event (ALTE) infants have had two periods, each of three months duration, free of significant alarms or apnea where vigorous stimulation or resuscitation was not needed. The provider must state the date of removal of the infant monitor on or in the final claim. 006.20(E) COVERED AND NON-COVERED COMPONENTS. Monitors that do not use rechargeable batteries are not covered. Separate payment for remote alarms will not be made. If provided, payment for a remote alarm is included in the monitor rental. Apnea monitor belts, lead wires, and reusable electrodes are covered for rented apnea monitors. 006.20(F) PNEUMOCARDIOGRAMS. Pneumocardiograms are covered for diagnostic or evaluation purposes and when required to determine when the infant may be removed from the monitor. Payment does not include analysis and interpretation. 006.20(G) BILLING. The hospital must bill for the technical component of infant apnea monitor services on the appropriate claim form or electronic format. The provider of the apnea monitor must state the date of removal of the infant monitor on the claim. Physicians' services must be billed as professional services on the appropriate Nebraska Medicaid approved claim form or the standard electronic claim. 006.21 HOME PHOTOTHERAPY. Rental of home phototherapy equipment for infants that require phototherapy is covered when neonatal hyperbilirubinemia is the infant's sole clinical problem when prescribed by and used under the supervision of a physician. To ensure that home phototherapy needs of infants are met, development of a coordination plan is required. The coordination plan is not an individual patient plan; it is an overall program outline for the delivery of home phototherapy services. 006.21(A) APPROVAL OF HOME PHOTOTHERAPY PROVIDERS. Rental of home phototherapy equipment provided by approved providers is covered. Physicians will not be approved as home phototherapy providers. 006.21(A)(i) HOME PHOTOTHERAPY REQUIREMENTS. The following conditions must be met prior to initiation of home phototherapy: (1) History and physical assessment by the infant's attending physician has occurred. If home phototherapy begins immediately upon discharge from the hospital, the newborn discharge exam will suffice; (2) Required laboratory studies have been performed, including, complete blood count (CBC), blood type on mother and infant, direct Coombs test, direct and indirect bilirubin; (3) The physician certifies that the parent or caregiver is capable of administering home phototherapy; (4) Parent or caregiver have successfully completed training on use of the equipment; and (5) Equipment must be delivered and set up within four hours of discharge from the hospital or notification of provider, whichever is more appropriate. There must be a 24-hour per day repair or replacement service available. 006.21(A)(ii) BILIRUBIN LEVEL. At a minimum, one bilirubin level must be obtained daily while the infant is receiving home phototherapy. 006.21(B) DISCONTINUING HOME PHOTOTHERAPY. Home phototherapy services will not be covered if the bilirubin level is less than 12 mgs at 72 hours of age or older. 006.21(C) DOCUMENTATION. A physician's narrative report outlining the beneficiary’s progress and the circumstances necessitating extended therapy must be submitted with the claim when billing for home phototherapy exceeding three days. 006.21(D) PAYMENT. Payment for home phototherapy services does not include physician's professional services or laboratory and radiology services related to home phototherapy. These services must be billed by the physician or laboratory performing the service. The daily rental payment includes: (i) Phototherapy unit and all supplies, accessories, and services necessary for proper functioning and effective use of the therapy; (ii) A minimum of one daily visit to the home by a licensed or certified health care professional is required. The daily visits must include: (1) A brief home assessment; and (2) Collection and delivery of blood specimens for bilirubin testing when ordered by the physician to be collected in the home. The physician must be informed by the provider that this service is available. An outside agency or laboratory with whom the provider contracts for collection and delivery of blood specimens may not bill Nebraska Medicaid directly since payment is included in the daily rental payment. Daily home visits must occur for home assessment even if the blood collection is done outside the home; and (iii) Complete caregiver training on use of equipment and completion of necessary records. 006.21(E) BILLING REQUIREMENTS. The provider must bill for home phototherapy daily rental services on a single claim and indicate the total number of rental days as the units of service using the appropriate claim form or electronic format as outpatient services. 006.22 COORDINATION PLAN REQUIREMENTS FOR CERTAIN SERVICES. Providers of apnea monitoring services and phototherapy services must maintain, as a part of the provider’s records, a coordination plan, which must include: (1) An overview of the services provided, including the provider's charge for the services; (2) Descriptions and literature on the equipment and all supplies and accessories provided; (3) Copies of all forms, instructions, and record sheets for beneficiary use; (4) An outline of the training format used to train the beneficiary on use of equipment and other training requirements; (5) The type and frequency of beneficiary contact and identification and qualifications of personnel conducting beneficiary contacts; and (6) A statement of the provider's policy on equipment set-up, servicing, and availability for consultation on equipment problems. 006.22(A) CHANGES TO COORDINATION PLAN. The provider must notify Nebraska Medicaid of any changes in the coordination plan. After review of the coordination plan, the provider may be required to amend the coordination plan. 006.22(B) APPROPRIATE HOSPITAL SERVICES. Appropriate home infant apnea monitor services provided by a hospital with an approved infant apnea monitor coordination plan includes rental of the apnea monitor; trend event recorder; and ECG or respirator recorder; purchase of related supplies; and CO2 hypoxia studies. 006.23 AMBULATORY ROOM AND BOARD. Ambulatory room and board is covered as a related transportation and as follows: 006.23(A) APPROVAL AS AN AMBULATORY ROOM AND BOARD PROVIDER. Only hospitals are approved as ambulatory room and board providers. To receive payment, each hospital providing ambulatory room and board services must be enrolled with Nebraska Medicaid as a provider for hospital services. 006.23(A)(i) PROVIDER RE-APPROVAL. Each hospital approved by Nebraska Medicaid to provide ambulatory room and board services must seek re-approval of its ambulatory room and board services from Nebraska Medicaid when any of the following occur: (1) The charge to Nebraska Medicaid for ambulatory room and board services changes; (2) There is a change in the physical location of the ambulatory room and board facility or the distance from the hospital building; (3) There is a change in the services the hospital is able to provide to beneficiaries in the ambulatory room and board facility; or (4) Other substantial changes are made to the hospital's ambulatory room and board services. 006.23(B) GUIDELINES. Ambulatory room and board services are covered when travel is necessary to seek medical care. Coverage of ambulatory room and board must meet the following guidelines : (1) The services must be necessary to secure Nebraska Medicaid coverable services, including medical examinations or treatment; (2) Meals are covered when receipt of Nebraska Medicaid coverable services requires the beneficiary to be away from their home for 12 hours or longer; (3) An out-of-town overnight stay is necessary while receiving Nebraska Medicaid coverable services or if coverage of ambulatory room and board services will prevent a hospital inpatient stay; (4) Meals and lodging for up to one day before or after receiving services if extensive travel is necessary; and (5) Up to one person who accompanies the beneficiary when the beneficiary is physically or mental unable to travel or wait alone. 006.23(B)(i) ADDITIONAL REQUIREMENT. Payment for ambulatory room and board services outside these requirements must be approved Nebraska Medicaid . 006.23(C) DOCUMENTATION. The hospital must include a statement that documents the necessity for ambulatory room and board services for a beneficiary or for a beneficiary and an attendant on the hospital claim. 006.23(D) BILLING AND PAYMENT. The hospital must bill for ambulatory room and board services provided by a Nebraska Medicaid enrolled hospital as an outpatient service on the appropriate claim form or electronic format and the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure codes. Payment will be made using a hospital-specific rate. Payment to the hospital must not exceed its charge for services provided to the general public.