471 Neb. Admin. Code, ch. 18, § 004

Current through September 17, 2024

Section 471-18-004 - SERVICE REQUIREMENTS

004.01MEDICAL NECESSITY. The definition of medical necessity from 471 NAC 1 is incorporated as if fully rewritten herein. Services and supplies which do not meet the 471 NAC 1 definition of medical necessity are not covered. Physicians' services may be provided at the physician's office, the individual's home, a hospital, a long term care facility, or elsewhere. Additionally, Nebraska Medicaid covers medically necessary physicians' services within program guidelines which are provided:

(A) Within the scope of the practice of medicine or osteopathy as defined by Nebraska state law; and

(B) By, or under the personal supervision of, an individual licensed under Nebraska state law to practice medicine or osteopathy.

004.02PRIOR AUTHORIZATION. For services provided to individuals enrolled in a managed care program, physicians must follow prior authorization guidelines of the applicable managed care plan. For all other individuals, physicians must request prior authorization from the Department 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; or

(10) Ventricular assist device.

004.02(A)PRIOR AUTHORIZATION PROCEDURES. Prior to providing the service, a request for prior authorization must be submitted by the physician using the standard electronic Health Care Services Review - Request for Review and Response transaction, Form ASC X12N 278.

004.02(A)(i)REQUEST FOR ADDITIONAL EVALUATIONS. The Department may request, and the provider must submit, additional evaluations when the Department determines the medical history for the request is questionable or when there is not sufficient information to support the requirements for authorization.

004.02(A)(ii)NOTIFICATION PROCESS. Upon determination of approval or denial, the Department provides a written notification, as applicable, to the physician submitting the request, the caseworker, and the medical review organization.

004.02(A)(iii)VERBAL AUTHORIZATION PROCEDURES. The Department may issue a verbal authorization when circumstances are of an emergency nature or urgent to the extent a delay would place the individual at risk of not receiving medical care. When a verbal authorization is granted, the standard electronic Health Care Services Review - Request for Review and Response transaction form must be submitted within 14 calendar days of the verbal authorization.

004.02(A)(iv)BILLING AND PAYMENT REQUIREMENTS. Claims submitted to the Department for services requiring prior authorization will not be paid without written or electronic approval. A copy of the approval documentation issued by the Department is not needed for submission with the claim unless instructed to do so as part of the authorization notification.

004.02(B)PRIOR AUTHORIZATION FOR PRESCRIPTION DRUGS. The Department requires authorization be granted prior to payment for certain drugs or items. Prior authorization may pertain to either certain drugs prescribed or certain physician administered drugs. Physicians wishing to prescribe these drugs must obtain prior authorization by submitting the request to either the Nebraska Point of Sale contractor or the Nebraska Medicaid pharmacy unit or its designee. The Department or the Nebraska Point of Sale contractor will respond to requests for prior authorization within 24 hours of receipt of the request. In cases of medical emergency, Nebraska Point of Sale contractor or the Department will authorize dispensing a 72 hour supply of a covered outpatient prescribed medication as described in 471 NAC 16.

004.02(C)PRODUCTS REQUIRING PRIOR APPROVAL. Identifiable products requiring approval prior to payment are designated as such on the Nebraska Point of Sale System or on the Department's website. The following prescribed products require prior approval:

(i) Sunscreen;

(ii) Certain modified versions, combinations, double-strength entities, or products considered by the Department to be equivalent to drug products contained on the state maximum allowable cost or federal upper limit listings in 471 NAC 16;

(iii) Human growth hormone;

(iv) Erythropoietin;

(v) Drugs or supplies intended for convenience use;

(vi) Drugs used for prevention of infection with respiratory syncytial virus;

(vii) Certain drugs or classes of drugs used for gastrointestinal disorders, including but not limited to hyperacidity, gastroesophageal reflux disease, ulcers, or dyspepsia;

(viii) Certain drugs or classes of drugs used for relief of pain, discomfort associated with musculoskeletal conditions, inflammation, or fever;

(ix) Certain drugs or classes of drugs used for relief of cough or symptoms of the common cold, influenza, or allergic conditions;

(x) Certain drugs or classes of drugs used for both non-covered services or indications and for covered services or indications;

(xi) Certain drugs or classes of drugs on the state maximum allowable cost or federal upper limit listings;

(xii) Certain drugs or classes of drugs upon initial availability or marketing or when Nebraska Medicaid coverage begins;

(xiii) Certain drugs or classes of drugs used for tobacco cessation; and

(xiv) Certain drugs or classes of drugs determined by the Pharmaceutical and Therapeutics Committee to not be placed onto the Preferred Drug List.

004.02(D)PRIOR AUTHORIZATION FOR PHYSICIAN ADMINISTERED DRUGS. The following drugs administered in the clinical setting require prior authorization:

(i) Any drug used for the prevention of respiratory syncytial virus infections;

(ii) Certain drugs used for the treatment of multiple sclerosis;

(iii) Enzyme replacement therapy (ERT) or lysomal storage disorders;

(iv) Immunoglobulin E (IgE) blocker therapies for asthma;

(v) Certain drugs or classes of drugs upon initial availability or marketing or when Nebraska Medicaid coverage begins; and

(vi) Drugs not covered under the Medicaid Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program.

004.02(E)PRIOR AUTHORIZATION FOR BARIATRIC SURGERY. Prior authorization requests must include, but are not limited to, documentation of:

(i) Medical diagnosis;

(ii) Body mass index (BMI) 35 or greater with one of the following co-morbidities:

(1) Diabetes mellitus, including recent laboratory results and current medications;

(2) Hypertension, including current medications, antihypertensive and blood pressure readings;

(3) Coronary artery disease (CAD), congestive heart failure (CHF), dyslipidemia, including recent laboratory results and current medications;

(4) Obstructive sleep apnea, including sleep study results and treatment;

(5) Gastroesophageal reflux disease (GERD), including test results and current medications being used to manage the symptoms;

(6) Osteoarthritis, including information about the individual's ability to ambulate, assistive devices used, and any medications being used to manage symptoms;

(7) Pseudotumor cerebri, including diagnostic reports, imaging; and

(8) Cardiac and pulmonary evaluations and, if existing, cardio-pulmonary co-morbidities and all related consults;

(iii) Dietary consultation, including documentation showing completion of a supervised diet program for six months or more, and a determination the individual is motivated to comply with dietary changes;

(iv) Psychiatry or Psychology consultation which includes:

(1) Evaluation to determine readiness for surgery and lifestyle change; and

(2) No behavior health disorder by history and physical exam;

(a) Exam includes no severe psychosis or personality disorder; and

(b) Mood or anxiety disorder excluded treatment. If treated, include treatment medications and modalities;

(v) Drug or alcohol screen;

(1) No drugs or alcohol by history, or alcohol and drug free for a period of at least one year; and

(2) No history of smoking, or smoking cessation has been attempted; and

(vi) individual's understanding of surgical risk, post procedure compliance and follow-up.

004.02(F)PRIOR AUTHORIZATION FOR TRANSPLANT SERVICES. Nebraska Medicaid requires prior authorization of all transplant services. Physicians must request and receive prior authorization before performing any transplant service or related donor service. The request for authorization must include, at a minimum:

(i) The individual's name, Medicaid identification number, and date of birth;

(ii) Diagnosis, pertinent past medical history and treatment, prognosis with and without the transplant, and the procedures for which the authorization is requested;

(iii) Name of the hospital, city, and state where the services will be performed, including the National Provider Identifier (NPI) of the provider;

(1) All providers must be enrolled with Nebraska Medicaid before services are performed. Out-of-state services are covered in accordance with 471 NAC 1;

(iv) Name of the physician who will perform the surgery if other than the physician requesting authorization;

(v) In addition to the above information, a physician specializing in the specific transplantation must also supply the following:

(1) The screening criteria used in determining an individual is an appropriate candidate for a liver, heart, allogenic, intestinal, or multi-visceral transplant;

(2) The results of the screening for the individual; and

(3) A written statement by the physician:

(a) Recommending the transplant;

(b) Certifying and explaining why the transplant is medically necessary as the only clinical, practical, and viable alternative to prolong the individual's life in a meaningful, qualitative way and at a reasonable level of functioning; and

(c) Including a psycho-social evaluation for solid organ transplants; and

(vi) For heart, lung, liver, stem cell, bone marrow, allogeneic, or intestinal or multi-visceral transplants, a second physician specializing in the specified transplant must also supply the above required information.

004.02(G)PRIOR AUTHORIZATION FOR NEW OR UNUSUAL SURGICAL PROCEDURES. A provider must request and receive prior authorization from the Department for all new or unusual surgical procedures. The provider must submit a copy of the notification of authorization only when instructed to do so in the text of the authorization.

004.02(H)PRIOR AUTHORIZATION FOR COSMETIC AND RECONSTRUCTIVE SURGERY. In addition to the prior authorization requirements included in this chapter, the surgeon who will be performing the cosmetic or reconstructive surgery must submit a request to the Department. This request must include the following:

(i) An overview of the medical condition and medical history of any conditions caused or aggravated by the condition;

(ii) Photographs of the involved area when appropriate to the request;

(iii) A description of the procedure being requested, including any plan to perform the procedure when it requires a staged process; and

(iv) When appropriate, additional information regarding the medical history may be submitted by the individual's primary care physician.

004.02(I)PRIOR AUTHORIZATION OF RADIOLOGY PROCEDURES. Nebraska Medicaid does not require prior authorization for individuals enrolled in fee-for-service needing radiology procedures. For members covered by a managed care organization, refer to the plan for prior authorization procedures.

004.02(J)PRIOR AUTHORIZATION FOR COMPREHENSIVE INTERDISCIPLINARY TREATMENT FOR A SEVERE FEEDING DISORDER. Prior authorization is required for all services before the services are provided. The requesting physician must submit a request to the Department including the following information or explanation as appropriate to the case:

(i) A referral from the primary care physician which includes current appropriate medical evaluations or treatment plans;

(ii) Medical records for the last year which include height and weight measurements; and

(iii) Any records from feeding and swallowing clinic evaluations and other therapeutic interventions which have occurred.

004.03DEFINITIONS AND TERMS OF COMMONALITY. The Current Procedural Terminology (CPT) contains terms and phrases common to the practice of medicine. Claims for physicians' services must be coded according to the definitions in the Current Procedural Terminology (CPT). At the request of the Department, the provider must submit copies of individual's medical records to document the level of care provided. If the requested documentation is not provided or is insufficient in contents, payment may be withheld or recouped. The Department recognizes the definitions and reporting requirements of the Current Procedural Terminology (CPT), but coverage of Nebraska Medicaid services is based on the regulations in NAC Title 471.

471 Neb. Admin. Code, ch. 18, § 004

Amended effective 7/5/2022

Amended effective 7/10/2022

Amended effective 9/17/2024