Kan. Admin. Regs. § 30-5-81

Current through Register Vol. 43, No. 45, November 7, 2024

Section 30-5-81 - Scope of hospital services

(a) Each hospital shall be medicare-certified and shall annually update medicaid enrollment information.

(b) Outpatient services shall be covered with the following limitations.

(1) Services shall be ordered by an attending physician who is not serving as an emergency room physician, except for those services related to emergency situations. Orders shall be related specifically to the present diagnosis of the recipient.

(2) A prosthetic device shall replace all or part of an internal body organ or shall replace one of these devices.

(3)

(A) Rehabilitative therapies shall be restorative in nature.

(B) Rehabilitative therapies shall be provided following physical debilitation due to acute physical trauma or physical illness.

(C) Rehabilitative therapies shall be prescribed by the attending physician.

(4) Services provided in the emergency department shall be emergency services.

(5) Elective surgery shall not be covered, except for sterilization operations or operations for Kan Be Healthy program participants.

(6) Ambulance services shall not be covered.

(7) Nonemergency visits in place of physician office visits shall be considered physician office visits and shall be counted against the physician office visit limitation.

(8) Outpatient hospital assessment of the need for emergency service shall not be covered.

(c) Inpatient services shall be covered, subject to the following limitations.

(1) Services shall be ordered by a physician and shall be related specifically to the present diagnosis of the recipient.

(2) Transplant surgery shall be limited to the following:

(A) Liver transplants, which shall be performed only at a hospital designated by the secretary unless the medical staff of that hospital recommends another location; and

(B) corneal, kidney, and bone marrow transplants and related services.

(3) A recipient of general hospital inpatient services shall not be billed for those days determined to be medically unnecessary. If a recipient refuses to leave a hospital after the recipient's physician writes a discharge order, the days after discharge that the recipient remains in the hospital may be billed to the recipient.

(4) A provider shall not be reimbursed for services provided on the day of discharge.

(5) Long-term care services in swing beds shall be provided pursuant to 42 CFR part 482, subpart E, revised October 1, 1999, which is adopted by reference.

(6) A provider shall not be reimbursed on an inpatient basis for therapeutic and diagnostic surgical services, and related services that can be performed on an outpatient basis. A provider shall not be reimbursed on an inpatient basis unless the service provider documents medical necessity.

(7) Inpatient services shall be subject to utilization review, which shall determine the following:

(A) Whether services are medically necessary;

(B) whether services are furnished at the appropriate level of care;

(C) whether services are of a quality that meets professionally recognized standards;

(D) whether a discharge is premature;

(E) whether a transfer is necessary; and

(F) whether the procedure coding and the diagnosis coding on a claim are correct.

(8) Psychotherapy, directed by a psychiatrist or approved hospital staff under the direction of a psychiatrist, shall be provided to each psychiatric patient on a daily basis.

(9) Substance abuse treatment services shall be limited to three treatment admissions per recipient's lifetime, regardless of the type of provider.

(10) Inpatient acute care related to substance abuse treatment services shall be limited to those patients who are in need of acute detoxification.

(11) Elective surgery shall not be covered, except for sterilization operations or operations for Kan Be Healthy program participants.

Kan. Admin. Regs. § 30-5-81

Authorized by and implementing K.S.A. 1999 Supp. 39-708c; effective May 1, 1981; modified, L. 1982, ch. 469, May 1, 1982; amended May 1, 1983; amended, T-84-7, March 29, 1983; amended, T-84-11, July 1, 1983; amended May 1, 1984; amended, T-85-9, April 11, 1984; amended, T-85-24, Sept. 18, 1984; amended May 1, 1985; amended May 1, 1986; amended May 1, 1987; amended May 1, 1988; amended, T-89-24, May 27, 1988; amended Sept. 26, 1988; amended, T-30-10-28-88, Oct. 28, 1988; amended Jan. 2, 1989; amended July 1, 1989; amended, T-30-7-29-89, July 29, 1989; amended Nov. 24, 1989; amended Aug. 1, 1990; amended, T-30-10-1-90, Oct. 1, 1990; amended Jan. 30, 1991; amended July 1, 1991; amended July 1, 1996; amended Oct. 6, 2000.