DAR File No. 28535

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-3A-6

Services

NOTICE OF PROPOSED RULE

DAR File No.: 28535
Filed: 02/28/2006, 05:23
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

Pursuant to public comment, this rulemaking is necessary to amend and clarify criteria for sleep studies in the Medicaid program.

Summary of the rule or change:

Subsection R414-3A-6(9) is amended because at this time no single entity approves sleep laboratories. Only staffing requirements for sleep laboratories exist.

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3, and 42 CFR 440.20

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this rulemaking because it only amends and clarifies criteria for sleep studies in the Medicaid program.

local governments:

There is no budget impact to local governments as a result of this rulemaking because it only amends and clarifies criteria for sleep studies in the Medicaid program.

other persons:

There is no budget impact to other persons as a result of this rulemaking because it only amends and clarifies criteria for sleep studies in the Medicaid program.

Compliance costs for affected persons:

There are no compliance costs because this rulemaking only amends and clarifies criteria for sleep studies in the Medicaid program.

Comments by the department head on the fiscal impact the rule may have on businesses:

These amendments are in response to public comment. They should have a positive fiscal impact on business. David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

04/14/2006

This rule may become effective on:

04/15/2006

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-3A. Outpatient Hospital Services.

R414-3A-6. Services.

(1) Services appropriate in the outpatient hospital setting for adequate diagnosis and treatment of a client's illness are limited to less than 24 hours and encompass medically necessary diagnostic, therapeutic, rehabilitative, or palliative medical services and supplies ordered by a physician or other practitioner of the healing arts.

(2) Outpatient hospital services include:

(a) the service of nurses or other personnel necessary to complete the service and provide patient care during the provision of service;

(b) the use of hospital facilities, equipment, and supplies; and

(c) the technical portion of clinical laboratory and radiology services.

(3) Laboratory services are limited to tests identified by the Centers for Medicare and Medicaid Services (CMS) where the individual laboratory is CLIA certified to provide, bill and receive Medicaid payment.

(4) Cosmetic, reconstructive, or plastic surgery is limited to:

(a) correction of a congenital anomaly;

(b) restoration of body form following an injury; or

(c) revision of severe disfiguring and extensive scars resulting from neoplastic surgery.

(5) Abortion procedures are limited to procedures certified as medically necessary, cleared by review of the medical record, approved by division consultants, and determined to meet the requirements of Utah Code 26-18-4 and 42 CFR 441.203.

(6) Sterilization procedures are limited to those that meet the requirements of 42 CFR 441, Subpart F.

(7) Nonphysician psychosocial counseling services are limited to evaluations and may be provided only through a prepaid mental health plan by a licensed clinical psychologist for:

(a) mentally retarded persons;

(b) cases identified through a CHEC/EPSDT screening; or

(c) victims of sexual abuse.

(8) Outpatient individualized observation of a mental health patient to prevent the patient from harming himself or others is not covered.

(9) Sleep studies are only available in a sleep laboratory [approved by the Board of Polysomnography Technologists. The laboratory must be ]staffed with at least one sleep medicine physician and one registered polysomnography technologist. The physician must be certified by the American Academy of Sleep Medicine. The polysomnography technologist must be registered through the Board of Polysomnography Technologists.

(10) Hyperbaric Oxygen Therapy is limited to service in a hospital facility in which the hyberbaric unit has been accredited or approved by the Undersea and Hyperbaric Medical Society.

(11) Lithotripsy is covered by an all-inclusive fixed fee. This payment covers all hospital and ambulatory surgery-related services for lithotripsy on the same kidney for 90 days, including repeat treatments. Lithotripsy for treatment of the other kidney is a separate service.

(12) Reimbursement for services in the emergency department is limited to codes and diagnoses that are medically necessary emergency services as described in the provider manual. The diagnosis reflecting the primary reason for emergency services must be used and must be one of the first five diagnoses listed on the claim form.

(13) Take home supplies and durable medical equipment are not reimbursable.

(14) Prescriptions are not a covered Medicaid service for a client with the designation "Emergency Services Only Program" printed on the Medicaid Identification Card.

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [February 1], 2006

Notice of Continuation: November 26, 2002

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-2.3; 26-18-3(2); 26-18-4

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.