471 NAC 20-026. ADULT DAY TREATMENT PSYCHIATRIC SERVICES

026. ADULT DAY TREATMENT PSYCHIATRIC SERVICES. . 026.01 COVERED DAY TREATMENT SERVICES. Psychiatric day treatment programs must provide the following mandatory services and at least two of the following optional services. Payment for both mandatory services and optional services is included in the rate for day treatment. Providers must not make any additional charges to Nebraska Medicaid or to the beneficiary. 026.01(A) MANDATORY SERVICES. The following services must be included in a program for psychiatric day treatment to be approved for participation in the Nebraska Medical Assistance Program. 026.01(A)(i) MEDICALLY NECESSARY PSYCHOTHERAPY SERVICES. These services must demonstrate active treatment of a beneficiary with a psychiatric condition. These services are subject to program limitations and must be provided by professionals operating within the appropriate scope of practice, including individual psychotherapy, group psychotherapy, family psychotherapy, and family assessment if appropriate. 026.01(A)(ii) MEDICALLY NECESSARY NURSING SERVICES. Services directed by a registered nurse (RN) who evaluates the particular medical nursing needs of each beneficiary and provides for the care and treatment that is indicated by Nebraska Medicaid approved treatment planning document approved by the supervising practitioner. 026.01(A)(iii) MEDICALLY NECESSARY PSYCHOLOGICAL DIAGNOSTIC SERVICES. Testing and evaluation services must reasonably be expected to contribute to the diagnosis and plan of care established for the individual beneficiary. Testing and evaluation services may be performed by a licensed psychologist. If testing and evaluation services are provided by a specially licensed psychologist or approved Master's level person, the services must be ordered by a supervising practitioner. Medical necessity must be documented by the supervising practitioner. Reimbursement for psychological diagnostic services is included in the per diem and will not be reimbursed for separately. 026.01(A)(iv) MEDICALLY NECESSARY PHARMACEUTICAL SERVICES. If medications are dispensed by the program, pharmacy services must be provided under the supervision of a registered pharmacy consultant; or the program may contract for these services through an outside facility that meets applicable provider participation requirements. All medications must be stored in a special locked storage space and administered only by a physician, physician assistant (PA), advanced practice registered nurse (APRN), registered nurse (RN), or licensed practical nurse (LPN). 026.01(A)(v) MEDICALLY NECESSARY DIETARY SERVICES. If meals are provided by a day treatment program, services must be supervised by a registered dietitian, based on the beneficiary's individualized medical diet needs. The program may contract for these services through an outside licensed certified facility. 026.01(A)(vi) TRANSITION AND DISCHARGE. Transition and discharge planning must meet the requirements of this chapter . 026.01(B) OPTIONAL SERVICES. The program must provide two of the following optional services. The beneficiary must have a need for the services, a supervising practitioner must order the services, and the services must be a part of the beneficiary's treatment plan. The therapies must be restorative in nature, not prescribed for conditions that have plateaued or cannot be significantly improved by the therapy, or which would be considered maintenance therapy. In appropriate circumstances, occupational therapy (OT) may be covered if prescribed as an activities therapy in a psychiatric program: (i)Services provided or supervised by a licensed or certified therapist may be provided under the supervision of a qualified consultant or the program may contract for these services from a professional that meets applicable provider participation requirements, as listed below: (1)Recreational therapy; (2)Speech therapy; (3)Occupational therapy (OT); (4)Vocational skills therapy; and (5)Self-care services: services supervised by a registered nurse (RN) or occupational therapist (OT) who is oriented toward activities of daily living and personal hygiene; (ii)Social work provided by a bachelor's level social worker: social services to assist with personal, family, and adjustment problems which may interfere with effective use of treatment ; (iii)Social skills building; and (iv)Life survival skills. 026.01(C) SPECIAL TREATMENT PROCEDURES IN DAY TREATMENT. If a beneficiary needs behavior management and containment beyond unlocked time outs or redirection, special treatment procedures may be utilized. Special treatment procedures in day treatment are limited to physical restraint, and locked time out (LTO). Mechanical restraints and pressure point tactics are not allowed. Facilities must meet the following standards regarding special treatment procedures: (i)De-escalation techniques must be taught to staff and used appropriately before the initiation of special treatment procedures; (ii)Special treatment procedures may be used only when a beneficiary's behavior presents a danger to self or others, or to prevent serious disruption to the therapeutic environment; and (iii)The beneficiary's treatment plan must address the use of special treatment procedures and have a clear plan to decrease the behavior requiring locked time out (LTO) or physical restraints. 026.01(D) STANDARDS DOCUMENTED. These standards must be reflected in all aspects of the treatment program. Attempts to de-escalate, the special treatment procedure and subsequent processing must be documented in the clinical record and reviewed by the supervising practitioner. 026.02 PROVIDER STANDARDS. Providers of day treatment services must meet the following standards: 026.02(A) NON-HOSPITAL BASED DAY TREATMENT. A center providing day treatment must be: (1)Appropriately licensed by the Nebraska Department of Health and Human Services, Division of Public Health; and (2)Accredited by the Joint Commission , the Commission on Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (COA), or the American Osteopathic Association (AOA). 026.02(A)(i) HOSPITAL BASED DAY TREATMENT. A hospital providing on-site day treatment must: (1)Be licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health; (2)Be accredited by the Joint Commission or the American Osteopathic Association (AOA); (3)Meet the requirements for participation in Medicare; and (4)Have in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries. 026.02(A)(ii) FREESTANDING FACILITIES. When hospitals provide services in freestanding facilities, the freestanding facility must be appropriately licensed by the Nebraska Department of Health and Human Services, Division of Public Health. 026.02(B) HOURS. The program must provide a minimum of three hours of services five days a week, which is considered a half day for billing purposes. A minimum of six hours a day is considered a full day of service. Services may not be prorated for under three hours of services for half day of service or six hours of services for full day of service. 026.02(B)(i) SUPERVISING PRACTITIONER. A designated supervising practitioner must be responsible for the psychiatric care in a day treatment program. The supervising practitioner must be present on a regularly-scheduled basis and must assume clinical responsibility for all patients. If the supervising practitioner is present on a part-time basis, one of the following must assume delegated professional responsibility for the program and must be present at all times when the program is providing services: (1)A licensed physician; (2)A licensed psychologist; (3)Licensed independent mental health practitioner (LIMHP); or (4)An allied health therapist. 026.02(B)(ii) REFERRAL. Any supervising practitioner may refer a beneficiary to a day treatment program, but all treatment must be prescribed and directed by the program supervising practitioner. 026.02(B)(iii) SUPERVISION. All treatment must be conducted under the supervision of the supervising practitioner in charge of the program. 026.02(B)(iv) PSYCHOTHERAPY STAFF. Psychotherapy staff as outlined in this chapter include the following: (1)Physician; (2)Licensed psychologist; (3)Licensed independent mental health practitioner (LIMHP); and (4)Allied health therapists. All psychotherapy services provided by allied health therapists must be prescribed by the supervising practitioner and provided under their supervision. The supervising practitioner's personal involvement in all aspects of the beneficiary's psychiatric care must be documented in the beneficiary's medical record through physician's orders, progress notes, and nurse’s notes. 026.02(B)(v) ADMISSION CRITERIA. The following criteria must be met for a beneficiary's admission to a psychiatric day treatment program: (1)The beneficiary must have sufficient medical need for active psychiatric treatment at the time of admission to justify the expenditure of the beneficiary's and program's time, energy, and resources; and (2)Of all reasonable options for active psychiatric treatment available to the beneficiary, treatment in this program must be the best choice for expecting a reasonable improvement in the beneficiary's psychiatric condition. 026.02(B)(vi) PRE-ADMISSION EVALUATION. Before the beneficiary is admitted to the program, the supervising practitioner must complete an initial diagnostic interview to validate the appropriateness of care. When a beneficiary is transferred from inpatient hospital care to day treatment, the inpatient evaluation and discharge summary documenting the rationale of transfer as part of the treatment plan serves the same purpose as the initial diagnostic interview. The evaluation must be filed in the beneficiary's medical record. The pre-admission evaluation must include: (1)A clinical assessment of the health status and related psychological, medical, social, and educational needs of the beneficiary; and (2)A determination of the range and kind of services required. 026.02(B)(vii) TREATMENT PLAN. The program supervising practitioner must determine the psychiatric diagnosis and prescribe the treatment, including the modalities and the professional staff to be used. The program supervising practitioner must be responsible and accountable for all evaluations and treatment provided to the beneficiary. The treatment plan must be completed upon the beneficiary's admission to the program. 026.02(B)(xiii) TREATMENT PLAN REVIEW. At least every 30 days thereafter, a treatment plan review must be conducted by the multi-disciplinary team, including the supervising practitioner. The treatment plan reviews must be documented. The treatment plan must be signed by the program supervising practitioner for day treatment services. 026.02(B)(ix) PERSONAL EVALUATION BY SUPERVISING PRACTITIONER. The supervising practitioner must personally evaluate the beneficiary every 30 days, or more often, as medically necessary. This evaluation must occur in a one-to-one, face-to-face session separate from the treatment plan review. 026.02(B)(x) UTILIZATION REVIEW. Every 30 days a utilization review must be conducted in accordance with this chapter. This review must be documented on the treatment plan. Utilization review is not required for the calendar month in which the beneficiary was admitted. 026.02(B)(xi) DESCRIPTIONS OF TREATMENTS AND SERVICES. The program must have a description of each of the services and treatment modalities available. This includes psychotherapy services, nursing services, psychological diagnostic services, pharmaceutical services, dietary services, and other psychiatric day treatment services: (1)The program must have a description of how the family-centered requirement in this chapter will be met, including a complete description of any family assessment and family psychotherapy services: (a) Providers must encourage family members to be involved in the assessment of the beneficiary, the development of the treatment plan, and all aspects of the beneficiary's treatment unless prohibited by the beneficiary, through legal action, or because of federal confidentiality laws; (b) Providers must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family's schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings; and (c) The provider must document their attempts to involve the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered. These may include, but should not be limited to, including the family via conference telephone calls, using registered letters to notify the family of meetings, and scheduling meetings in the evening and on weekends; (2)The program must have a description of how the community-based requirement in this chapter will be met; (3)The program must state the qualifications, education, and experience of each staff member and the therapy services each provides; and (4)The program must have a daily schedule covering the total number of hours the program operates per day. The schedule must be submitted to Nebraska Medicaid for approval. The program must be fully staffed and supervised during the time the program is available for services and must provide at least three hours of approved treatment for each day services are provided. This schedule must be updated annually, or more frequently if appropriate. 026.02(B)(xii) OUTPATIENT OBSERVATION. When appropriate for brief crisis stabilization, outpatient observation up to 23 hours 59 minutes in an emergency room or acute hospital may be used. If a beneficiary receives 24 or more hours of continuous outpatient care, that beneficiary is defined as an inpatient regardless of the hour of admission, whether they used a bed and whether they remained in the hospital past midnight or the census-taking hour, and all inpatient medical review prior-authorization requirements apply. 026.02(B)(xiii) INPATIENT SERVICES PLAN. The program must have a written plan for immediate admission or readmission for appropriate inpatient psychiatric services, if necessary. The written plan must include a cooperative agreement with a psychiatric hospital or distinct part of a hospital, as outlined in this chapter . A copy of this agreement must accompany the provider application and agreement. 026.03 PROVIDER AGREEMENT. The provider must attach to the provider application and agreement a written overview of the program including philosophy, objectives, policies and procedures, confirmation that the requirements in this chapter are met, and any other information requested by Nebraska Medicaid . Staff must meet the standards outlined in this chapter; and: (A)Community mental health programs and licensed mental health clinics must complete the appropriate Nebraska Medicaid approved provider agreement form , and submit the completed form to Nebraska Medicaid for approval. The provider application and agreement must be renewed annually to coincide with the submittal of the cost report. Satellites of community mental health programs must bill Nebraska Medicaid through their main community mental health program, unless the satellite has a separate provider number under Medicare. A satellite of a community mental health program that has a separate provider number under Medicare must complete a separate provider agreement. All claims submitted to Nebraska Medicaid by these satellites must be filed under the satellite's Nebraska Medicaid provider number. The facility must have in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries; and (B)Hospitals must complete the appropriate Nebraska Medicaid approved provider agreement form and submit the completed form to Nebraska Medicaid for approval. 026.03(i) ANNUAL UPDATE. The program must update the provider agreement, program overview, and cost report annually and whenever requested by Nebraska Medicaid . 026.04 COVERAGE CRITERIA FOR DAY TREATMENT PSYCHIATRIC SERVICES. Nebraska Medicaid covers psychiatric day treatment services for beneficiaries age 21 and over when the services meet the requirements in this chapter. 026.04(A) OBSERVATION AND INTERVIEW. The beneficiary must be observed and interviewed by the program supervising practitioner at least every 30 days or more frequently if medically necessary and the interaction must be documented in the beneficiary's medical record. 026.04(B) SERVICES NOT COVERED UNDER NEBRASKA MEDICAID. Payment is not available for psychiatric day treatment services for beneficiaries :- (i)Receiving services in an out-of-state facility, except as outlined in this title ; (ii)Living in long-term care facilities or institutes for mental disease (IMD); (iii)Whose needs are social or educational and may be met through a less structured program; (iv)Whose primary diagnosis and functional impairment is psychiatric in nature but is not stable enough to allow them to participate in and benefit from the program; or (v)Whose behavior may be very disruptive or harmful to other program participants or staff members. 026.05 DOCUMENTATION IN THE BENEFICIARY’S RECORD. All documents submitted to Nebraska Medicaid must contain sufficient information for identification . Each beneficiary's clinical record must contain the following documentation: (A)The supervising practitioner's orders; (B)The initial diagnostic interview and referral documented by the supervising practitioner; (C)The treatment plan; (D)The team progress notes, recorded chronologically. The frequency is determined by the beneficiary's condition, but the team's progress notes must be recorded at least weekly. The progress notes must contain a concise assessment of the beneficiary's progress and recommendations for revising the treatment plan, as indicated by the beneficiary's condition, and discharge planning; (E)Documentation indicating compliance with all requirements in this chapter; (F)The program's utilization review committee's abstract or summary; and (G)The discharge summary. 026.06 TRANSITION AND DISCHARGE PLANNING. Each provider must meet the requirements in this chapter for transition and discharge planning. 026.07 UTILIZATION REVIEW. Each program is responsible for establishing a utilization review plan and procedure which meets the following requirements. A site visit by Nebraska Medicaid for purposes of utilization review may be required for further clarification. 026.07(A) COMPONENTS OF UTILIZATION REVIEW. Utilization review must provide: (i)Timely review, at least every 30 days, of the medical necessity of admissions and continued treatment; (ii)Utilization of professional services provided; (iii)High quality patient care; and (iv)Effective and efficient utilization of available health facilities and services. 026.07(B) UTILIZATION REVIEW OVERVIEW. An overview of the program's utilization review process must be submitted with the provider application and agreement before the program is enrolled as a Nebraska Medicaid provider. The overview must include: (i)The organization and composition of the utilization review committee which is responsible for the utilization review function; (ii)The frequency of meetings, which must occur at least once every 30 days ; (iii)The type of records to be kept; and (iv)The arrangement for committee reports and their dissemination, including how the supervising practitioner is informed of the findings. 026.07(C) UTILIZATION REVIEW COMMITTEE. The utilization review committee must consist of a supervising practitioner and at least two mental health practitioners as defined in this chapter. A licensed psychologist may replace one of the allied health staff members. The committee's reviews may not be conducted by any person whose primary interest in or responsibility to the program is financial or who is professionally involved in the care of the client whose case is being reviewed. At Nebraska Medicaid's discretion, an alternative plan for facilities that do not have these resources readily available may be approved. 026.07(D) BASIS OF REVIEW. The review must be based on: (i)The identification of the individual beneficiary by appropriate means to ensure confidentiality; (ii)The identification of the supervising practitioner; (iii)The date of admission; (iv)The diagnosis and symptoms; (v)The supervising practitioner plan of treatment; and (vi)Other supporting materials the group may deem appropriate. 026.07(E) CONTENTS OF REPORT. A copy of the admission review and the extended stay review must be attached to all claims for psychiatric services submitted to Nebraska Medicaid for payment. In addition, the written report must contain: (i)An evaluation of treatment, progress, and prognosis based on: (1)Appropriateness of the current level of care and treatment; (2)Alternate levels of care and treatment available; and (3)The effective and efficient utilization of services provided; (ii)Verification that: (1)Treatment provided is documented in the beneficiary's record; (2)All entries in the beneficiary's record are signed by the person responsible for entry. The supervising practitioner must sign all orders; and (3)All entries in the beneficiary's record are dated; (iii)Recommendations for: (1)Continued treatment; (2)Alternate treatment or level of care; and (3)Disapproval of continued treatment; (iv)The date of the review; (v)The names of the program utilization review committee members; and (vi)The date of the next review if continued treatment is recommended. 026.08 PAYMENT FOR PSYCHIATRIC DAY TREATMENT SERVICES. Payment for psychiatric day treatment services will be based upon rate setting by Nebraska Medicaid . 026.08(A) PAYMENT RATES. Payment rates for psychiatric day treatment services for beneficiaries age 21 and older will be on a unit basis. Rates are set annually, for the period July 1 through June 30. Rates are set prospectively for this period, and are not adjusted during the rate period. 026.08(B) COST REPORTS. Providers are required to report their costs on an annual basis. Providers may choose any fiscal year end that they desire. Providers desiring to enter the program who have not previously reported their costs, or that are newly operated, are to submit a budgeted cost report, estimating their anticipated annual costs. 026.08(C) COST AND STATISTICAL DATA REQUIREMENTS. Providers must submit cost and statistical data on the appropriate Nebraska Medicaid approved cost reporting document . The provider must submit one original Nebraska Medicaid approved cost reporting document to Nebraska Medicaid within 90 days of the close of fiscal year, or change in ownership or management. One 15-day extension may be granted under extenuating circumstances if requested, in writing, prior to the date. Providers must compile data based on generally accepted accounting principles and the accrual method of accounting based on the provider's fiscal year. Financial and statistical records for the period covered by the cost report must be accurate and sufficiently detailed to substantiate the data reported. All records must be readily available upon request by Nebraska Medicaid for verification. If the provider fails to file a cost report as due, Nebraska Medicaid will suspend payment. At the time the suspension is imposed, Nebraska Medicaid will send a letter informing the provider that no further payment will be made until a proper cost report is filed. 026.08(D) COSTS CONSIDERED. In setting payment rates, Nebraska Medicaid will consider those costs which are reasonable and necessary for the active treatment of the beneficiaries being served. Such costs will include those necessary for licensure and accreditation, meeting all staffing standards for participation, meeting all service standards for participation, meeting all requirements for active treatment, maintaining medical records, conducting utilization review, meeting inspection of care requirements and discharge planning. 026.08(E) NOT ALL COSTS REIMBURSED. Nebraska Medicaid does not guarantee that all costs will be reimbursed. The cost reporting document is used by Nebraska Medicaid only as a guide in the rate setting process. Actual costs incurred by the providers may not be entirely reimbursed. 026.08(F) PAYMENT RATES FOR PSYCHIATRIC DAY TREATMENT SERVICES PROVIDED BY THE STATE. Psychiatric day treatment centers operated by the State of Nebraska will be reimbursed for all reasonable and necessary costs of operation, excluding educational services. State-operated centers will receive an interim payment rate, with an adjustment to actual costs following the cost reporting period. 026.08(G) UNALLOWABLE COSTS. The following costs are not allowable: (i)Provisions for income tax; (ii)Fees paid board of directors; (iii)Non-working officers' salaries; (iv)Promotion expense, except for promotion and advertising as allowed in HIM-15. Yellow Page display advertising is not allowable; one Yellow Page informational listing is allowable; (v)Travel and entertainment, other than for professional meetings and direct operations of the day treatment program ; (vi)Donations; (vii)Expenses of non-related facilities and operations included in expense; (viii)Insurance and annuity premiums on the life of officer or owner; (ix)Bad debts, charity, and courtesy allowances; (x)Cost and portions of costs which are determined by Nebraska Medicaid not to be reasonably related to the efficient production of service because of either the nature or amount of the particular expenditure; (xi)Education costs; (xii)Services provided by the beneficiaries' physicians or dentists, drugs, laboratory services, radiology services, or services provided by similar independent licensed providers, except services provided by state operated facilities. These exclusions are paid separately; (xiii)Return on equity; (xiv)Costs for services which occurred in a prior or subsequent fiscal year ; (xv)Expenses for equipment, facilities, and programs provided to beneficiaries which are determined by Nebraska Medicaid not to be reasonably related to the efficient production of service because of either the nature or amount of the particular service; (xvi)Costs of amusements, social activities, and related expenses for employees and governing body members , except when part of an authorized beneficiary treatment program; (xvii)Costs of alcoholic beverages ; (xviii)Costs resulting from violations of, or failure to comply with federal, state, and local laws and regulations ; (xix)Costs relating to lobbying or attempts to influence or promote legislative action by local, state, or federal government ; and (xx)Costs of lawsuits or other legal or court proceedings against Nebraska Medicaid , or its employees, or State of Nebraska . 026.08(H) SUSPENSION OR TERMINATION OF LICENSE. Nebraska Medicaid does not make payment for care provided after 30 days following the date of expiration or termination of the provider's license or certificate to operate under Title XIX. Nebraska Medicaid does not make payment for care provided to beneficiaries who were admitted after the date of expiration or termination of the provider's license or certificate to operate under Title XIX. 026.08(I) APPEAL PROCESS. Final administrative decision or inaction in the rate setting process is subject to administrative appeal. The provider may request an appeal, in writing, from the Director for a hearing within 90 days of the decision or inaction. 026.08(J) ADMINISTRATIVE FINALITY. An administrative decision or inaction in the allowable cost determination process, which is otherwise final, may be reopened by Nebraska Medicaid within three years of the date of notice of the decision or inaction. 026.08(K) REOPENING. Reopening is an action taken by the Medicaid and Long-Term Care Director to re-examine or question the correctness of a determination or decision which is otherwise final. The Director of Medicaid and Long-Term Care is the sole authority for deciding whether to reopen an administrative decision or inaction. The action may be taken: (i) On the initiative of Nebraska Medicaid within the three-year period; (ii) In response to a written request of a provider or other entity within the three-year period. Whether the Director of Medicaid and Long-Term Care will reopen a determination, which is otherwise final, depends on whether new and material evidence has been submitted, a clear and obvious error has been made, or the determination is found to be inconsistent with any law, regulations , or general instructions; or (iii) Any time fraud or abuse is suspected. 025.08(K)(1) NO APPEAL RIGHT. A provider has no right to appeal a finding by the Director of Medicaid and Long-Term Care that a reopening or correction of a determination or decision is not warranted. 026.09 RECORD RETENTION. The provider must retain financial records, supporting documents, statistical records, and all other pertinent records related to the cost report for a minimum of five years after the end of the report period. 026.10 BILLING REQUIREMENTS. For day treatment services, the following requirements must be met: (A) Providers of non-hospital based day treatment services must submit claims for day treatment services on the appropriate Nebraska Medicaid approved health care claim form or electronic claim. Payment for approved day treatment services is made to the facility; and (B) Providers of hospital-based day treatment services must submit claims for services on the appropriate Nebraska Medicaid approved health care claim form or electronic claim. Payment for approved hospital based day treatment services is made to the hospital. 026.10(i) DOCUMENTATION FOR CLAIMS. The following documentation, kept in the beneficiary’s file, is required for all claims for day treatment services: (1)Initial diagnostic interview; (2)Supervising practitioner orders; (3)Nurses' notes; and (4)Progress notes for all disciplines. 026.10(i)(a) UTILIZATION REVIEW. All claims are subject to utilization review by Nebraska Medicaid prior to payment. 026.10(ii) EXCEPTION. Additional documentation from the beneficiary's medical record may be requested by Nebraska Medicaid prior to considering authorization of payment. Progress notes for other Nebraska Medicaid beneficiaries may be requested when the treatment report does not adequately explain family psychotherapy or medical necessity cannot be determined. 026.11 PROCEDURE CODES AND DESCRIPTIONS FOR PSYCHIATRIC DAY TREATMENT. Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes used by Nebraska Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule . 026.12 COSTS NOT INCLUDED IN THE DAY TREATMENT FEE. The mandatory and optional services are considered to be part of the fee for day treatment services. The following charges can be reimbursed separately from the day treatment fee when the services are necessary, part of the beneficiary's overall treatment plan, and in compliance with Nebraska Medicaid requirements: (A)Direct beneficiary services performed by the supervising practitioner; (B)Prescription medications including injectable medications; (C)Direct beneficiary services performed by a physician or advanced practice registered nurse (APRN) other than the supervising practitioner; and (D)Treatment services for a physical injury or illness provided by other professionals. 026.12(i) SECOND MANAGED CARE VENDOR. If the beneficiary is enrolled with another managed care vendor for medical-surgical services, it may be necessary to pursue prior authorization or referral with that entity.